Medicare Compliance & Reimbursement

The old saying, "If it wasn't documented, it wasn't done" has taken on a whole new meaning at one MAC.

Highmark Medicare Services, the Part B carrier for six states, recently listed the CERT errors that it found during a random claims check between July and September of 2010. Highmark found that 18 out of 52 errors weredue to insufficient documentation and 29 were due to incorrect coding.

The majority of the errors for insufficient documentation were related to the fact that the medical record documentation did not contain a valid physician's signature or the radiology report/diagnostic test did not contain a valid physician order or identification of the provider who rendered the service, the Highmark report noted.

The vast majority of the coding errors involved E/M codes. "The reasons for the errors were due to the fact that the provider's documentation did not substantiate the level of care billed based on one or more of the key components (history, exam, medical decision making) being coded at the incorrect level," the report indicated.

Editor's Note: To read the full report, visit www.highmarkmedicareservices.com/cert/errors/b-cert-anl-octdec.html.