Medicare Compliance & Reimbursement

Take note of the four-pronged approach used by CERT reviewers.

You don’t want to cause an auditor’s biggest headache. Messy records or illegible documentation are bad enough, but missing documentation will most assuredly land you in hot water.

Find What the Auditor Is Missing

This is the heart of a recent Comprehensive Error Rate Testing (CERT) finding, which the Centers for Medicare & Medicaid Services’ (CMS) published in its most recent Medicare Quarterly Provider Compliance Newsletter. Noting that reviewers are “vexed by insufficient documentation,” the agency says that it can be very difficult for reviewers to get documentation, often having to “use investigative measures” to find the source of the records, and even then hitting dead ends. Needless to say, if your records don’t support the codes you’ve billed, Medicare will want you to give back any money paid to you for those services, which means that missing documentation could cost you a fortune.

CERT reviewers noted that they used a four-pronged approach to seeking documentation from providers, including phone calls and faxes, personal conversations, requests for clinicians to sign attestation statements for medical records that were missing signatures, and searching the internet to find providers. “Even with this intensive follow-up effort,” CMS said, “Documentation frequently was either not obtained or did not contain the information necessary to properly pay the claim.”

Common issue: CERT auditors will frequently ask a provider for an item that’s missing from the documentation and will just receive a response including the exact same records they already have. For instance, if an ophthalmologist billed 92133 (Scanning computerized ophthalmic diagnostic imaging…) but did not include a retinal drawing in the medical documentation, the auditor might request it. In one situation, the ophthalmologist agreed to send such a drawing, but instead simply re-sent the same documentation from the original records, with no drawing. The MAC denied the original claim for 92133.

If you find yourself in this situation, don’t try to save time by resubmitting the same documentation again. Instead, take the time to find the missing information and get it to the auditor as soon as possible so you won’t have to repay the MAC.

Auditor on the Way? Do This

If auditors tell you they want to review your records, don’t panic. Auditors aren’t necessarily on a witch-hunt — they may find no wrongdoing at all in your documentation.

You should pull all encounters that have been selected for audit with all of the accompanying documentation, and double-check that everything required is in each file. For example, if your provider performed physical therapy, ensure that the physician’s order for it is with the documentation — otherwise you will have to look for it later.

Important: If you do find any issues while preparing your records for audit, do not alter documentation, change billing records, destroy records, or in any other way compromise the information. You may want to contact your practice’s attorney for advice on how to present the missing information to the auditor.

Resource: To read the recent Medicare Quarterly Provider Compliance Newsletter, which discusses the auditors’ findings, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909051.pdf.