Understanding Medicare Documentation Requirements

Brittany Tomkies
Executive Editor
Loyola University Chicago School of Law, JD 2017


With more than one billion claims processed annually by the Medicare Fee-For Service (FFS) Program for more than one million health care professionals, understanding and identifying common errors encountered by Medicare Administrative Contractors (MACs) and other contractors such as Recovery Auditors (RACs) and Comprehensive Error Rate Testing (CERT) review contractors may help your organization achieve better billing compliance.

Last month HHS CMS’ Medicare Learning Network (MLN) released Volume 7, Issue 1 of the Medicare Quarterly Provider Compliance Newsletter, Guidance to Address Billing Errors. The newsletter is designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare FFS Program and includes guidance to help health care professionals address and avoid the top issues of the particular Quarter. Archived issues are available and can be searched by a provider-specific index or keyword index.

This quarter’s newsletter focused on six different procedures reviewed by CERTs and RACs including balloon angioplasties, endovenous ablation therapy of incompetent veins, blepharoplasties, transurethral resection of the prostate, post acute care transfers and skilled nursing facilities coding validation.

For each of the procedures, MLN provides background information, a description of the study, findings, examples of improper payments, guidances and additional resources. For example, the CERT Review Contractor conducted a special study of claims with lines for venous transluminal balloon angioplasty procedures billed with HCPCS code 35476 and submitted between April and June 2015. The CERT Contractor found that most improper payments were due to insufficient documentation from the medical records submitted and noted that most often, there was no documentation to support the medical need for the procedure, no procedure note and/or no physician’s signature on a procedure note, diagnostic report or progress note.

Three specific examples were provided. In the first, an interventional radiologist billed for HCPCS 35476 and, in response to the CERT contractor’s request for documentation, submitted a letter to the CERT program and a procedure note. However, the submitted documentation was missing a physician’s authenticated clinical documentation to support the reason/need for procedure and missing a physician’s order for or documentation to support intent to order transluminal balloon angioplasty. The CERT medical reviewer requested additional documentation but did not receive any further documentation. The CERT program did not consider the provider’s letter because there was no documentation in the beneficiary’s medical record documentation to corroborate the information in the letter. MLN noted that physician attestations by themselves do NOT provide sufficient documentation of medical necessity, even if signed by the ordering physician. For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary’s medical documentation and confirm that Medicare coverage criteria have been met.

In a second example, a nephrologist billed for HCPCS 35476 and, in response to the CERT contractor’s request for documentation, submitted a progress/procedure note and a referral form. However, the submitted documentation was missing a physician’s order form or documentation to support intent to order a fistulagram and angioplasty. In addition, there was no authenticated physician clinical documentation to support the reason/need for the procedure to be performed. CERT received no additional documentation despite phone calls and requests for additional documentation.

In the third example, a general surgeon billed for HCPCS 35476 and, in response to the CERT contractor’s request for documentation, submitted a physician’s progress note documenting clotted dialysis access to left upper arm arteriovenous (AV) graft needing a thrombectomy with the performance of thrombectomy with Tissue Plasminogen Activator (TPA) and multi-level angioplasty that is not signed and a duplicate progress note that was altered to include a signature (no attestation statement submitted). The submitted documentation was missing the performing physician’s attestation statement.

In all three examples, CERT scored the claim as an insufficient documentation error and the MAC recovered the payment from the provider.

Insufficient documentation was a common theme in this quarter’s MLN newsletter as well as older issues. However, many of these errors may be avoided with a proper understanding of Medicare FFS requirements and a thorough review of CMS guidelines for proper documentation.

As the MLN newsletter noted, 42 CFR 424.5(a)(6) requires “the provider, supplier, or beneficiary, as appropriate, [to] furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.” Many resources are available to help providers understand this regulation. For example, CMS issued the 1995 Documentation Guidelines for Evaluation and Management Services and 1997 Documentation Guidelines for Evaluation and Management Services, which outline the general principles of medical record documentation. The guidelines also detail documentation of evaluation and management (E/M) services, documentation of patient history, documentation of the patient examination, documentation of the complexity of medical decision making and documentation of an encounter dominated by counseling or coordination of care. Further, in August 2016, MLN released guidance on Evaluation and Management Services which discusses medical record documentation as well as common billing and coding considerations for E/M services.

A November 2014 fact sheet, Complying With Medical Records Documentation Requirements, issued by MLN in conjunction with CERT and Durable Medical Equipment MAC Outreach & Education Task Forces provides educational resources to aid providers in understanding how to provide accurate and supportive medical record documentation.

Finally, resources like Guidelines for Teaching Physicians, Interns and Residents are great educational resources because they explicitly state what must be documented for coverage. For example, the resources states that to qualify for payment, “The teaching anesthesiologist or different anesthesiologist(s) in the same anesthesia group must be present during all critical or key portions of the anesthesia service or procedure; and [t]he teaching anesthesiologist or another anesthesiologist with whom he or she has entered into an arrangement must be immediately available to provide anesthesia.” Further, the record must document that “The teaching anesthesiologist’s presence during all critical or key portions of the anesthesia procedure; and [t]he immediate availability of another teaching anesthesiologist as necessary.”

Regulations like those found at 42 CFR 424.5(a)(6) are often vague and difficult to interpret, but many resources exist to assist in better understanding documentation requirements. Real, tangible examples like those illustrated in the Medicare Quarterly Provider Compliance Newsletter may help your providers better understand both documentation requirements as well as the consequences of insufficient documentation and should be regularly distributed to affected individuals. Further, incorporating these resources into compliance training may allow for a more open dialogue between compliance staff and providers and staff to more efficiently and effectively address documentation inadequacies.