Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 17, 2012 PDF

Plus: If you aren't ready for 5010 yet, it's time to kick your efforts into high gear.

You have most likely heard the phrase "if it wasn't documented, it wasn't done" so many times that it's old hat--and yet, insufficient documentation remains one of the biggest denial reasons among Medicare contractors. The OIG tried to improve upon that denial rate by offering practices a second chance to turn in required documentation--but the majority passed on the offer, leaving contractors no choice but to request a refund of the money that practices had received for those services.

Background: When CERT (Comprehensive Error Rate Testing) reviewers find that Medicare paid for claims that are missing documentation, CERT reviewers contact the practices up to three times to request complete documentation to support the claims. In cases when the documentation is not sufficient, the practices have to return the money to the Medicare program.

Following a review of the 2010 CERT results, which featured a 10.5 percent error rate (totaling $34.3 billion), the OIG offered practices yet another chance to send in required documentation to support their services. However, only 34 percent of practices that the OIG contacted submitted additional documentation that allowed the CERT contractor to overturn its claim payment denials.

The remaining 66 percent of providers did not submit documentation that supported the medical necessity of their claims, which meant they forfeited the reimbursement they had received for those services.

Although the 34 percent that did resubmit documentation allowed the OIG to calculate a lower claims error rate than the original CERT report, the fact that less than half of practices submitted documentation to support their services should be a wake-up call.

Best practice: Maintain thorough and legible documentation for all services that you perform and bill. And if the OIG or your MAC offers you an opportunity to hang on to your reimbursement via medical record submission, you should take it.

To read the OIG report, visit http://oig.hhs.gov/oas/reports/region10/11100502.pdf.