Documentation Guidelines for Medicare Services - JE Part B

Incomplete or illegible records can result in denial of payment for services billed to Medicare. In order for a claim for Medicare benefits to be valid, there must be sufficient documentation in the provider's or hospital's records to verify the services performed were "reasonable and necessary" and required the level of care billed. If there is no or insufficient documentation, then there is no justification for the services or level of care billed. Additionally, if there is insufficient documentation on the claims that have already been adjudicated by Medicare, reimbursement may be considered an overpayment and the funds can be partially or fully recovered.

Medical records should be complete, legible, and include the following information.

• Reason for encounter, relevant history, findings, test results and date of service
• Assessment and impression of diagnosis
• Plan of care with date and legible identity of observer
• Documentation that supports rendering/billing provider indicated on claim is healthcare professional providing service.
  • Medicare must identify rendering provider of a service not only for use in standard claims transactions but also for review, fraud detection, and planning policies. In order to accomplish this, Noridian must be able to determine and verify rendering physician/practitioner for each patient service billed to Medicare. It is very important that individual(s) performing a billed service is/are identified
• Records should not only substantiate service performed but also required level of care

By law, Medicare contractors (carriers/fiscal intermediaries, Medicare Administrative Contractors, (MAC), Comprehensive Error Rate Testing (CERT), Recovery Auditor (RA) and Unified Program Integrity Contractor (UPIC) can review any information, including medical records, pertaining to a Medicare claim.

When a physician/supplier provides diagnostic services; the documentation must include the following.

• An order. An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields a result determined by the treating physician/practitioner to require the additional test (e.g., if test X is negative, then perform test Y). An order may be delivered via:
  • A written document signed by treating physician/practitioner, which is hand-delivered, mailed, or faxed to testing facility;
    • No signature is required on orders for clinical diagnostic tests paid on basis of clinical laboratory fee schedule, physician fee schedule, or for physician pathology services;
  • A telephone call by treating physician/practitioner or his/her office to testing facility (If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records. While a physician order is not required to be separately signed, the physician must clearly document, in the medical record, his or her intent that the test be performed); or
  • An electronic mail by treating physician/practitioner or his/her office to testing facility.

• Progress notes supporting medical necessity of diagnostic services. If "testing facility" is billing for the diagnostic services, it is their responsibility to get these notes from the treating physician.
  • A "testing facility" is a Medicare provider or supplier that furnishes diagnostic tests. A testing facility may include a physician or a group of physicians (e.g., radiologist, pathologist), a laboratory, or an independent diagnostic testing facility (IDTF).

Providers billing Medicare for their services must act in accordance with the following conditions.

• Document in appropriate office records and/or hospital records each time a covered Medicare service is provided
• When providing concurrent care for hospital or custodial care facility patients, physicians should identify his/her specialty where this helps support necessity
• Write medical information legibly and sign each entry with a legible signature, or ensure that provider's/author's/observer's identity is present and legible
• Medical information should be clear, concise, and reflect patient's condition
• Progress notes for hospital and custodial care facility patients must have all entries dated and signed by healthcare provider who actually examined the patient
• Provide sufficient detail to support necessity for diagnostic tests that were furnished and level of care billed
• Not use statements such as "same as above" or ditto marks ("). This is not acceptable documentation that service was provided on that date

The "burden of proof" remains with the provider to substantiate services and/or supplies billed to Medicare. During the audit process, if documentation is needed, the physician or supplier must provide the required documentation within the deadlines stipulated in the written request.