Physicians receive requests for documentation on a daily basis. Insurer requests need particular attention, as they can be directly related to reimbursement. If the documentation supports the service, payment is rendered (pre-payment request) or maintained (post-payment request). If the documentation is not supportive, payment is denied (pre-payment request) or refunded (post-payment request).
The two most common reasons submitted documentation is not supportive: It lacks information or only a portion of the documentation was submitted.
Not Enough Documentation
“Insufficient documentation” can take many forms. Each visit category (e.g., initial hospital care or subsequent hospital care) and level of service (e.g., 99221-99233) has corresponding documentation requirements. A full list of requirements is available on the Centers for Medicare and Medicaid Services Web site (www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf). Selecting an evaluation and management (E/M) level is focused on either upon the content of three key components: history, exam, and decision-making; time can also be a consideration but only when counseling or coordination of care dominate more than 50% of the physician’s total visit time.1 Failure to document any essential element in a given visit level (e.g., family history required but missing for 99222 and 99223) might result in a reviewer down-coding or denying the service.
Dates and signatures are vital to each encounter. The reviewer must be able to identify each individual who performs, documents, and bills for a service, as well as when the service occurred. Notes that lack dates or signatures are not considered in support of a billed service. Notes that contain an illegible signature are equally problematic. If the legibility of a signature prevents the reviewer from correctly identifying the rendering physician, the service can be denied.
It is advisable for the physician to print their name alongside the signature on the encounter note, or include a separate signature sheet with the requested documentation to assist the reviewer in deciphering the physician’s scrawl. Keep in mind that stamped signatures are not acceptable. Medicare accepts handwritten signatures, electronic signatures, or facsimiles of original written or electronic signatures.2
A service is questioned when two different sets of handwriting appear on a note and only one signature is provided. Because the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.
Many times, an encounter note does not contain the cumulative information representing the reported service. For example, other pieces of pertinent information might be included in the data section or order section of the chart. If the individual responsible for gathering the requested documentation does not review the information before submitting it, those other important entries could be missed, and the complexity of the billed service might not be justified.
To avoid this, have the designated individual review the note for specific references to information housed in different areas of the chart. The provider should submit any entry with the same date as the requested documentation: labs, diagnostic testing, physician orders, patient instructions, nursing notes, resident notes, notes by other physicians in the same group, discharge summaries, etc.
Legibility is crucial when the documentation is sent for review. Note that the reviewer will not contact the provider if the information is not readable. Most reviewers seek another reviewer’s assistance in translating the handwriting, but they are not obligated to do this. If the note is deemed incomprehensible, the service is denied.
Electronic health records (EHR) are assisting physicians and other providers with legibility issues, and can help take the guesswork out of the note’s content. If a physician is still writing notes by hand, a transcription could be sent along with the documentation to prevent unnecessary denials. It is not advisable to do this for all requests, but only for requests involving providers who have particularly problematic handwriting.
Timeliness of Response
Once the documentation request is received, the physician has a small window of opportunity to review the request, collect the information, and issue a response. A lack of physician response always results in a service denial or a refund request. Once denied, the physician must go through the proper channels of appeal (with a different insurer reviewing department). Requests for refunds are more difficult to overturn. It is difficult to “open” a case that has been “closed.” Denials resulting from a failure to respond to a pre-payment request are a bit easier to resolve because the resulting denial is typically the payor’s initial determination of the claim. The physician usually is allowed an appeal of the payor’s initial determination. However, it is not a cost-effective process to handle prepayment requests in this manner. Always attempt to respond to the initial request within the designated time frame. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
- Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008;79-109.
- Centers for Medicare and Medicaid Services: CR 5971 Clarification-Signature Requirements. Medicare Learning Network Web site. Available at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0829.pdf. Accessed Sept. 1, 2009.
- Pohlig C. Evaluation and Management Services: An Overview. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians, 2008; 65-78.