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Outpatient FAQ July 2018

Published on 

Tuesday, July 10, 2018

 | RAC Information 
 | FAQ 

Q:

Services for Medicare patients referred to our hospital for outpatient treatments or testing are being denied by Medicare due to “clinical documentation not provided.”  Examples of the types of services being denied are therapeutic outpatient infusions and diagnostic tests such as CT scans. The only information the hospital has is the physician’s order and the nursing documentation or diagnostic report. How are we supposed to provide the clinical documentation to support the medical necessity of the service to the Medicare auditor?

A:

Information addressing this can be found in the Medicare Program Integrity Manual, Chapter 3. The bottom line is the billing provider is ultimately responsible for submitting all supporting documentation for services for which they billed, even if they have to obtain such information from another provider. 

Medicare auditors include the:

  • Medicare Administrative Contractors - MACs,
  • Recovery Auditors - RACs,
  • Comprehensive Error Rate Testing reviewers - CERT and
  • Zone or Unified Program Integrity Contractors - ZPICs/UPICs.

These auditors generally request documentation to support the services billed to Medicare from the billing provider. The CERT, and at their discretion, other Medicare auditors, may also request information from the referring provider when such information is not sent in by the billing supplier/provider initially and after a request for additional documentation fails to produce medical documentation necessary to support the service billed and supported by the Local and National Coverage Determinations.

However, because the provider selected for review or appealing a denial is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the requested documentation.  This means hospitals may have to obtain information supporting the medical necessity of services from the referring provider, such as physician office notes, and forward that documentation to the Medicare auditor. Failure to get this documentation to the Medicare auditor can result in payment denial for the billed service.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was 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.

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.