Medicare Compliance & Reimbursement

Tip: Know the Medicare rules on medical record amendments.

One of the most important factors of concise medical documentation is that it allows you to track a beneficiary’s progress over time; plus, it helps you collect payment for services performed. But not all Medicare providers keep their documentation in tiptop shape — and that can spell doom for your practice’s bottom line.

That was the word from CGS Medicare’s Lisa Addison during the Part B payer’s webinar, “Principles of Documentation.” Addison outlined several important tips that can allow you to perfect your practice’s documentation and generate clean claims.

Understand Why Strong Documentation Is Essential

Maintaining pristine documentation should be the goal of every practice because it allows you to justify the reasons you performed certain services or ordered particular supplies, tests, or imaging services. This will, in turn, ensure that payers see the full picture of what the practice clinicians do during a particular visit, as well as why they did it.

“The purpose of having good documentation is to show that a claim has met all of the necessary coverage criteria for medical necessity,” Addison said. This can help you determine if your claim will be covered by your payer. “Most policies contain coverage and documentation requirements that are unique to that specific policy … it’s so important that you review the relevant local coverage determination (LCD) to ensure you have all the information necessary for the item or service you’re providing to the beneficiary,” she added.

For instance, an LCD might indicate that a particular procedure isn’t payable unless the physician has documentation of a slit lamp test report on file. Always review the LCDs most applicable to your services and update your physicians when LCD requirements change. And remember: If you didn’t document it, it didn’t happen.

Save Documentation for 7 Years

Documentation doesn’t expire after your claim is paid. In reality, you must be able to retain it for years.

“Be sure you have access to all medical records upon request. You’re required to maintain all documentation and medical records for seven years,” Addison advised. “If Medicare has paid a claim and conducts a post-pay audit and you cannot produce the supporting documentation upon request, Medicare will recoup the money paid on the claim,” she continued. “The documentation is there to validate the site of service; the medical necessity and appropriateness of the supplies, equipment, and services provided; and/or that items furnished have been accurately reported.”

CMS Doesn’t Dictate Record Format

In most cases, your practice is free to maintain documentation in the media format that works best for you, Addison said. Although some practices believe they must maintain paper copies of all claims, that’s not necessarily the case.

The Centers for Medicare & Medicaid Services (CMS) doesn’t have requirements dictating the media formats for medical records, but “the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities,” CGS guidance indicates.

You Can Amend the Medical Record — If You Follow the Rules