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.
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