Medicare Compliance Newsletter – Documentation and Discharge Status

on Monday, 27 April 2015. All News Items | Outpatient Services | Documentation

Learning through Repetition

We all know the requirements for medical record documentation to support services billed to Medicare, or do we? Just to name a few – a signed order or documentation of intent to order, signed and dated operative or procedure notes, signed plans of care when applicable, a signature log or attestation for illegible signatures, tests results, the correct date of service, and the reason for the service to support medical necessity. We should all know because we have been told … and told again … and told again. It reminds me of a childhood joke: Pete and Repeat were sitting on a log; Pete fell off so who was left? When the listener replies “Repeat” the joke is repeated over and over. Amusing for children, but is this necessary for adults? With continuing billing errors, I think Medicare would say emphatically “YES.”

The Medicare Quarterly Provider Compliance Newsletter for April 2015 examines several billing errors affecting hospitals that occurred due to insufficient documentation. Instead of simply restating the documentation requirements, I thought it would be more informative (and entertaining!) to list specific examples of what the CERT reviewers received and didn’t receive to support the services billed.

CERT Review of Radiation Therapy Planning (CPT codes 77300 and 77301)

All of the improper payments were due to insufficient documentation.

  • Notes for dates of service different from those billed
  • An unsigned and undated treatment plan
  • An unsigned fine needle aspiration report
  • An undated histogram
  • An unsigned operative report
  • No documentation of complex treatment devices
  • No verification of treatment setup and delivery
  • No signature attestation statement
  • No progress notes to document the order/intent to order radiation therapy prior to billed date of service
  • No authenticated copy of the dosimetry calculation for date of service
  • No documentation showing that basic radiation dosimetry calculation was performed on the billed date of service

CERT Review of Transcatheter Aortic Valve Replacement/Implantation (TAVR/TAVI) (CPT codes 33361, 33362, 33365)

The vast majority of the improper payments were due to insufficient documentation.

  • No documentation of preoperative face-to-face evaluations with the cardiovascular surgeon or the interventional cardiologist as required by the NCD
  • An unsigned operative note and then a duplicate unsigned operative note
  • An unsigned intra-operative echocardiogram report
  • An undated unsigned dictated preoperative visit note (which stated “final recommendations will follow”)
  • Only one preoperative face-to-face evaluation submitted and it was unauthenticated
  • A note was received which stated, “We regret to inform you that we are unable to process your request as the patient did not receive services on the service dates requested."
  • A second note was received that stated "Request needs to be sent to hospital for documentation on need" - it is the billing provider (in this case, the physician) who is responsible for providing documentation to support services billed.

CERT Review of Laboratory Services (unlisted chemistry procedure – CPT 84999)

Most improper payments were due to insufficient documentation.

  • Documentation that the date of service was neither the date of collection nor the date the test was performed
  • A single quantitative gene activity report when the test was described as an analysis of the quantitative activity of multiple genes
  • An unsigned requisition with no signed and dated clinical records supporting the intent to order the test

Another issue addressed in this quarter’s compliance newsletter is RAC findings related to the incorrect reporting of discharge status codes under Medicare’s Post-Acute Care Transfer Policy. This automated review compares the discharge status reported by the hospital to claims data received by Medicare indicating the patient received post-acute care. To comply with this policy, hospitals must have:

  1. Coders who know the correct discharge status codes;
  2. Clear documentation in the medical record by the physician, case manager or discharge planner of the patient’s post-discharge plans; and
  3. Processes in place to follow up with patients after discharge to ensure there were no changes in post-discharge care plans.

For anyone interested in more information, MMP offers a one hour on-demand educational class for an overview of discharge status codes, Medicare’s acute-to-acute and post-acute care transfer policies, how to correctly apply the codes, and tips on best processes for compliance. You can purchase this class at

Even as adult learners, repetition of information is an effective way to learn.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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