CMS Tightens Documentation and Signature Requirements

Two recent publications issued by CMS clearly indicate that the organization is tightening its requirements for the documentation required to support medical necessity and mandated signatures on prescriptions and orders for services.

The first publication is the "Improper Medicare Fee for Service Payments Report of November 2009." This report details the type and percentage of errors found in claims as determined by reviews performed under the CERT (Comprehensive Error Rate Testing) program. Page 9 of this document describes changes in what is acceptable and not acceptable for documentation to support the medical necessity of services provided.

Impact of the More Stringent Review Criteria

The more stringent review criteria for review of claims selected for the November 2009 report resulted in increases in error rates due to:

Records from the treating physician not submitted or incomplete

In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

Missing evidence of the treating physician's intent to order diagnostic tests

In the past, CERT would consider an unsigned requisition or physicians' signatures on test results. Now, CERT requires evidence of the treating physician's intent to order tests, including signed orders and/or progress notes.

Medical records from the treating physician did not substantiate what was billed

Again, in the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

Missing or illegible signatures on medical record documentation

In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures. Now, CERT disallows entries if a signature is missing or illegible.

CERT Contractors Advised

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