Submit Proper Documentation for Surgical Services
The main reason Medicare denies claims is because there is insufficient documentation in the medical record. For all surgical services, make sure the medical record has these four elements:
- Correct date of service
- Reason for procedure
- Signed operative report
- Physician signature and/or signature log or attestation for an illegible signature
Showing medical necessity is only one piece of the puzzle, however.
A general statement signed by the ordering physician saying that conservative treatment measures were tried and failed, is not enough. You must provide supporting documentation for the services being billed.
Documentation Improvement Tip
The Certified Documentation Expert Outpatient (CDEO®) credential validates a documentation professional’s expertese in reviewing outpatient documentation for accuracy in the support of coding, quality measures, and clinical requirements. Learn more about the CDEO credential.
Latest posts by Renee Dustman (see all)
- Learn How Part B Payment is Changing for Practitioners - November 20, 2018
- CMS Discloses Requirements for Positive Payments Under MIPS in 2021 - November 16, 2018
- CMS Waives Medicare Regulations for California - November 15, 2018
AAPC's annual salary survey gives a good understanding of the earning potential within the medical coding profession.
See what actually is going on in the healthcare business job market.