Medicare Compliance & Reimbursement

If you’re performing CT scans, it’s a good time to check your documentation. CMS recently found a 16 percent improper payment rate among practices reporting these services, and the agency took a moment to remind CT scan practitioners about the importance of accurate documentation in a Medicare Learning Network Podcast on the topic.

“Insufficient documentation caused more than 99 percent of the CERT review contractor identified improper payments,” CMS reps said on the podcast. “Insufficient documentation means that something was missing from the medical records. Missing orders caused over half of the payment denials.”

To prevent denials, the CMS staffer advised that you first check the ordering practitioner’s order to ensure that it’s signed, and then retain a copy of that order. In addition, you should document the fact that you performed the CT scan, and retain a copy of the CT scan report from the radiologist or interpreting physician. If your Medicare contractor asks for your documentation, send along the original order for the scan, the ordering practitioner’s progress notes documenting the reason for the scan, the medical records that you created during the scan and the final report of the scan that the radiologist or interpreting doctor provides.