Insufficient documentation is the root cause for most of CMS’s improper payments. For example, according to the Medicare-Fee-For-Service 2016 Improper Payments Report, CMS paid $36.3 billion in improper payments, 64.1% of which were attributed to insufficient documentation.
The guiding rule is if it didn’t happen in the documentation, then it didn’t happen at all. The EMR must support all services and procedures done that day, both for payment and for audit purposes. Most of the time where this is missed is in the recording of the time of the visit. This documentation is key to supporting visit levels and procedures.
Much of this documentation discrepancy can fall around ACP’s or Advanced Care Planning. If the note does not include the time spent on the ACP, a provider can submit office notes, procedure notes, test results, hospital records, etc., and still have the money recouped.
According to a study from the U.S. Department of Health and Human Services, top insufficient documentation errors are:
• Missing/Inadequate Orders – A valid provider’s order was not submitted
• Missing/Inadequate Plan of Care – A valid plan of care was not submitted
• Missing/Inadequate Records – required records were not submitted or were not fully completed.
• Inconsistent Records – This could be an incorrect date, service, beneficiary, etc.
• Certification/Recertification – requirements not met.
We know most providers today use templates in their documentation. Templates are a great way to make noting easier and more efficient for providers. However, if templates do not include things like time spent face -to face with the patient, the practice is leaving itself open to numerous recoups for insufficient documentation. Make sure your templates include an area where you can document time spent. Also, properly amend notes when necessary to ensure all documentation is accounted for in the medical record. Taking just a few of these steps will help prevent recoups when additional documentation is requested from CMS.