Note from the CDI Education Director: Ensuring Compliance with Medicare Documentation Requirements
by Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS
In the evolving landscape of Medicare Fee-for-Service (FFS) reviews, compliance with medical documentation requirements is crucial for ensuring proper reimbursement and avoiding costly overpayments. The Centers for Medicare & Medicaid Services (CMS) recently issued a bulletin through the Medicare Learning Network (MLN), highlighting new documentation guidelines and providing additional resources for Medicare documentation compliance.
Below, I’ve outlined the key takeaways from this latest guidance, the role of healthcare professionals in the documentation process, and best practices for ensuring accurate and supportive medical records.
Key documentation requirements
CMS has reinforced the need for complete and accurate documentation to justify the services billed. This includes:
- Progress notes and office visit records
- Documentation from previous visits supporting ongoing or related care
- Care plans written by supervising physicians or nonphysician practitioners
- Lab orders for recurring or follow-up tests
- Records detailing incident-to services
Incomplete or missing documentation may result in denied payments or the recoupment of previously reimbursed funds.
Medicare review and documentation requests
Medicare review entities may submit additional documentation requests (ADR) to healthcare facilities during audits or reviews. These requests come from several types of Medicare FFS reviewers, including:
- Medicare Administrative Contractors (MAC)
- Supplemental Medical Review Contractors (SMRC)
- Recovery Audit Contractors (RAC)
- Unified Program Integrity Contractors (UPIC)
The time frame for submitting documentation in response to an ADR ranges from 30 to 45 days, depending on the type of reviewer and whether the review is pre-payment or post-payment. While there is minimal leeway in these deadlines, exceptions may apply in cases of natural disasters, business interruptions, or other extenuating circumstances.
Comprehensive Error Rate Testing Program
The Comprehensive Error Rate Testing (CERT) program plays a vital role in assessing improper payments in the Medicare FFS program. CMS uses CERT to:
- Review random sample claims to detect overpayments and underpayments
- Determine whether the submitted documentation supports the billed services
- Identify improper payments resulting from insufficient, incomplete, or missing documentation
To comply with CERT reviews, providers must submit detailed and accurate documentation that supports:
- Medicare coverage criteria
- Proper coding practices
- Billing requirements.
The role of health information, CDI, and coding teams
Health information (HI) professionals, CDI specialists, and coding teams play a critical role in ensuring compliant documentation. Their responsibilities include:
- Ensuring documentation validity.
- Validating that medical records accurately reflect the level of care billed
- Confirming that records are complete, detailed, and aligned with CMS policies
- Ensuring complete medical records. A medical record is considered complete by CMS if it contains sufficient information to:
- Identify the patient
- Support the diagnosis/condition
- Justify the care, treatment, and services
- Document the course and results of care, treatment, and services
- Promote continuity of care among providers
- Releasing queries to reviewers.
- To support the documentation review, release of information staff should include query responses and physician clarifications with ADR submissions
- Educating providers.
- Collaborate with physicians to promote thorough and specific documentation practices
- Reinforce the importance of documenting medical necessity, clinical support, and service validation
- Utilize educational tools appropriately
Inpatient documentation
For Uniform Hospital Discharge Data Set (UHDDS) reporting purposes, the definition of other includes only those conditions that affect the episode of hospital care in terms of any of the following:
- Clinical evaluation
- Therapeutic treatment
- Further evaluation by diagnostic studies, procedures, or consultation
- Extended length of hospital stay
- Increased nursing care and/or other monitoring
Per the ICD-10-CM Official Guidelines for Coding and Reporting Section I.A.19, Code Assignment and Clinical Criteria, “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”
While this means that a provider’s documentation of the condition being present is sufficient, it also must be held against the UHDDS guidelines for clinical support.
Educate providers to clinically validate their documentation by using thinking and phrasing such as:
Diagnosis of________ and the etiology is ________, as evidenced by ___________,
and the plan is to ________.
Outpatient documentation
Per the Official Guidelines for Coding and Reporting sections IV.I and IV.J:
- “Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”
- “Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).”
The risks of insufficient documentation
CMS explicitly states that it may deny payments for services with incomplete or insufficient documentation. While illegibility is less of an issue with electronic health records (EHR), incomplete or vague documentation remains a major concern. If post-payment reviews reveal insufficient documentation, CMS may classify the payment as an overpayment and seek partial or full recovery.
Best practices for compliance
To protect against payment denials and ensure proper reimbursement, consider the following:
- Prioritize thorough documentation:
- Ensure that all services billed have corresponding detailed records supporting medical necessity
- Include relevant clinical notes, test results, and care plans
- Enhance CDI and coding collaboration:
- Foster ongoing communication between CDI specialists, coders, and providers to ensure alignment of documentation practices
- Use regular educational sessions to reinforce proper documentation techniques
- Respond promptly to ADRs:
- Ensure that your ROI release of information staff sends complete and accurate records to reviewers within the specified 30-to-45-day time frame
- Include all relevant records, such as queries, lab results, and prior visit notes, to avoid denials based on insufficient documentation
- Leverage CMS resources:
- Utilize CMS’s updated documentation guidelines and reference materials to stay current with evolving requirements
- Incorporate regular audits and internal reviews to identify and address potential compliance and documentation gaps
The recent CMS bulletin underscores the critical importance of thorough and accurate documentation in Medicare FFS claims. As healthcare organizations continue to navigate the complexities of Medicare reviews, health information, CDI, and coding teams must remain vigilant in ensuring that documentation supports medical necessity, billing accuracy, and compliance with CMS regulations.
By prioritizing comprehensive documentation practices and fostering collaboration among documentation and coding professionals, healthcare providers can safeguard against payment denials, minimize financial risk, and maintain compliance with Medicare guidelines.
Editor’s note: Wilk is the CDI education director at ACDIS/HCPro. Contact her at deanne.wilk@hcpro.com