Knowledge Base Article

Oh, the sounds of summer – waves crashing on the beach, birds chirping, bees buzzing, crickets filling the night with their chirping, and lawn mowers humming. Yes, lawn care is very much a necessary part of our summer routine and Americans love their pristine lawns. We even pay lawn care companies to spray our yards with fertilizers, weed control, insect and grub control, pre-emergents, and chemicals to prevent lawn diseases. The lawn care technician leaves a receipt listing the treatments which were applied that day. But what if you received your bill and there were charges for treatments that the technician did not include on your receipt? The receipt is all you have to verify what was done and you know what they say – “if it’s not documented, it wasn’t done.”  This is not necessarily true, but for payment and legal purposes it is the standard. Those of us working in healthcare are very familiar with this adage, but Medicare review contractors still deny numerous claims for insufficient documentation.

Here are some tips about proper documentation to support the Medicare services provided that I present as Know, Respond, Gather, and Sign.

1. KNOW – It is the provider’s responsibility to know the Medicare documentation requirements to support provision and billing of services. Providers should not wait until they receive an Additional Documentation Request (ADR) to review the coverage and documentation requirements. Instead, providers should have processes in place to ensure the services meet Medicare’s requirements prior to the provision of the services. Coverage and documentation rules can be found in various Medicare publications, such as Medicare coverage policies – national coverage determinations (NCDs) and local coverage determinations (LCDs). In addition to explaining the conditions for which a service is covered, these policies often explain what documentation is required in the medical record to substantiate the medical necessity of the service. Some requirements, such as the need for a signed certification of a plan of care for rehabilitative therapy services, can be found in the Medicare manuals. Other sources of information target those services for which Medicare reviewers have identified ongoing errors. Since the ongoing errors may result in continuing audits of these services, providers need to carefully review educational materials which address these. The Medicare Quarterly Provider Compliance Newsletter, facts sheets such as Complying with Medical Record Documentation Requirements, and audit findings from the individual Medicare Administrative Contractors (MACs) on their websites all offer great guidance for documentation of services at higher risk of review.
2. RESPOND – There are often a large number of denials for Medicare reviews because of a lack of a timely response to the ADR. For example, in a review by the Supplemental Medical Review Contractor (SMRC) for SPECT scans 65% of denials were because providers did not respond to the ADR timely. Providers need to have systems in place to identify ADRs, route them to the appropriate hospital department, and respond with complete records in the appropriate time frame.
3. GATHER – In responding to an ADR request, providers must have the knowledge discussed above about the documentation needed to support the services. Knowing what is required will allow you to gather the relevant information in your response to Medicare. And you may have to look outside your own medical record to find what is needed to support your billing. The fact sheet referenced about states, “it is the billing provider’s responsibility to obtain supporting documentation as needed from a referring physician’s office (for example, physician order, notes to support medical necessity) or from an inpatient facility (for example, progress note).” Here are some examples that occur often:
4. A laboratory test is performed and billed based on a lab requisition form that is not signed (per Medicare rules, it doesn’t have to be), but Medicare does require a signed order from the referring physician to support the billing. This may be a signed note in the physician’s office record stating that this particular lab test be ordered.
5. Some services require that the patient first receive and fail conservative treatments before having this more extensive or invasive service. Medicare requires details of which conservative treatments were tried. Again, this information may be found in the physician’s office notes and the billing provider (such as the hospital) may have to obtain and send this documentation with their ADR response. It is advisable to require the physicians provide this information to the facility before performing the service. Then you are not scrambling on the back end to locate the documentation that is needed to support your services.
6. The need for some services is supported by previously performed diagnostic studies, such as x-rays or laboratory tests findings. The results of these tests may be in the physician’s office record, at another testing entity, or in a prior hospital record. You must gather this information to include in your ADR response.
7. SIGN – Medicare requires that services that are ordered or provided must be authenticated by the ordering practitioner. Sounds easy enough but evidently, based on Medicare review findings, remains a challenge for providers. Signatures can be legible handwritten signature or electronic authentication. Signatures should happen in a timely manner so your options in responding to an ADR are limited if orders and other documentation are not already signed. Medicare does not allow late signatures, but will accept a signature attestation for certain types of unsigned documentation (other than orders). An unsigned order is considered invalid during a Medicare review. Illegible signatures may be accepted if accompanied by an attestation or a signature log.  For complete information regarding Medicare signature requirements, see the Fact Sheet Complying with Medicare Signature Requirements and section 3.3.2.4 of the Medicare Program Integrity Manual. 

Those are my tips for responding to Medicare ADRs so hopefully your hospital can avoid the “not documented, not done” and the “not signed, not valid” snares of Medicare reviewers.