Insufficient Documentation No. 1 Reason for Claims Denials

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  • August 12, 2015
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Insufficient Documentation No. 1 Reason for Claims Denials

Insufficient documentation caused more than 94 percent of Comprehensive Error Rate Testing (CERT) review contractor-identified improper payments during the 2014 reporting period, according to the Centers for Medicare & Medicaid Services (CMS). Missing physician orders caused more than half of those payment denials.
Radiology is a particularly vulnerable area because most procedures require a physician’s order. Computed tomography (CT) scans, alone, had an improper payment rate of 13 percent, last year.
CMS offers three tips, via its Medicare Learning Network, for ensuring proper documentation of CT scans:

  1. Make sure the order from the ordering physician is signed and retain a copy of the signed order in the patient’s medical record;
  2. Verify the CT scan was performed and documented as such; and
  3. Retain a copy of the radiology report in the patient’s record.

Medicare administrative contractor Cahaba GBA also reminds providers in provider outreach and education materials to ask the ever-important question: Does the patient’s condition support use of a CT scan?
To assess medical necessity, confirm that the patient’s symptoms and complaints support an initial diagnostic test. For example, “periodic headaches” would not support the need for a CT scan, per the National Coverage Determination (NCD) for Computed Tomography (220.1).

Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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