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Complying with Medical Record
Documentation Requirements
MLN909160 March 2024
What’s Changed?
Note: No substantive content updates.
MLN Fact SheetComplying with Medical Record Documentation Requirements
MLN909160 March 2024Page 2 of 5
CMS uses the Comprehensive Error Rate Testing (CERT) program to measure improper payments in
the Medicare Fee-for-Service (FFS) Program. Under CERT, we review a random sample of Medicare
FFS claims to determine if we paid them correctly under Medicare coverage, coding, and billing rules.
Once the CERT program identies a claim in the sample, it requests (via fax, letter, or phone call) the
associated medical records and other related documentation from the provider or supplier who submitted
the claim. CERT medical review professionals then examine the claim and related documentation.
The CERT program is managed by 2 contractors:
●
The CERT Statistical Contractor determines how claims
are sampled and calculates any improper payments
●
The CERT Review Contractor requests and reviews
medical records from providers and suppliers
Third-Party Additional Documentation Requests
When CERT requests a review, the billing provider must get supporting documentation (for example,
physician’s order or notes to support medical necessity) from a referring physician’s oce or from an
inpatient facility, skilled nursing facility, or other location where records (for example, progress notes)
are kept to support the services billed, ordered, or provided.
The billing provider should submit the requested
documentation because they’re the enity whose
payment CERT reviews.
We pay for necessary services, but patient medical
record documentation must show their medical
necessity. Instruct medical record sta and third-party
medical record copy services to provide all records
that support payment. This may include records for
services before the date of services listed on the
medical record request. Examples include:
●
A signed oce note from a previous visit where the
provider ordered a diagnostic or other service
●
The care plan written by the supervising physician
who bills for an “incident to” service
●
For incident to services, the care plan written by
the supervising physician or non-physician
practitioner (NPP)
●
Lab orders for recurring tests to meet the specic
needs of an individual patient
Submit enough documentation
to support your claims.
MLN Fact SheetComplying with Medical Record Documentation Requirements
MLN909160 March 2024Page 3 of 5
Insucient Documentation Errors
CERT reviewers determine claims have errors when the medical documentation submitted is insucient
to support Medicare payment for the services billed (that is, the reviewer couldn’t conclude some of the
allowed services were actually provided, were provided at the level billed, or were medically necessary).
Reviewers also place claims into this category when a specic documentation element that’s required
as a condition of payment is missing, like a physician signature on an order, or a form that’s not
entirely completed.
CERT identies insucient documentation errors that may include:
●
Incomplete progress notes (for example, unsigned, undated, insucient detail)
●
Unauthenticated medical records (for example, no provider signature, no supervising signature,
illegible signatures without a signature log or attestation to identify the signer, and an electronic
signature without the electronic record protocol or policy that documents the process for
electronic signatures)
●
No documentation of intent to order services and procedures (for example, incomplete or missing
signed order or progress note describing intent for services to be provided)
Common Procedures with Insucient Documentation Errors
Vertebral Augmentation Procedures
●
Missing signature and date on clinical documentation that supports the patient’s symptoms
●
No radiographs that support the procedure’s medical necessity
●
Insucient medical record documentation (for example, medication administration records, therapy
discharge summary) that the provider tried conservative medical management, but it failed or
was contraindicated
●
No signed and dated attestation statement for the operative report if a physician signature was
missing or illegible (or missing the operative report if the statement is electronically signed)
Physical Therapy Services
●
Documentation didn’t support certication of the plan of care for physical therapy services
●
We require the physician’s or NPP’s signature and date of certication of the plan of care or progress
note indicating they reviewed and approved the plan of care
MLN Fact SheetComplying with Medical Record Documentation Requirements
MLN909160 March 2024Page 4 of 5
Evaluation & Management (E/M) Services
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CERT identied oce visits (established), hospital (initial), and hospital (subsequent) as the top
3 errors in E/M service categories
●
High errors consisted of insucient documentation, medical necessity, and incorrect coding of E/M
services to support medical necessity and accurate billing of those services
Durable Medical Equipment (DME)
●
Certain DME HCPCS codes (like hospital beds, glucose monitors, and manual wheelchairs) require
a valid standard written order prior to claim submission
●
The practitioner’s name or NPI must be on the valid standard written order
●
We’ll pay claims only for DME if the ordering physician and DME supplier are actively enrolled in
Medicare on the date of service
●
As a condition for payment, a physician, physician assistant, nurse practitioner, or certied nurse
specialist must document a face-to-face encounter exam with a patient in the 6 months before the
written order for certain DME items
MLN Fact SheetComplying with Medical Record Documentation Requirements
MLN909160 March 2024Page 5 of 5
Computed Tomography (CT) Scans
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Documentation of the plan or intent to order a CT scan was insucient to support its medical necessity
●
If the handwritten signature is illegible, include a signature log (if electronic, include the protocol)
Provider Compliance has more information about how to avoid common coverage, coding, and
billing errors.
Resources
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Section 220.1.3 of the Medicare Benet Policy Manual, Chapter 15: Certication and
Recertication of Need for Treatment and Therapy Plans of Care
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Section 220.4 of the Medicare Benet Policy Manual, Chapter 15: Functional Reporting
●
Section 220.1.1 of the Medicare Benet Policy Manual, Chapter 15: Care of a Physician/
Nonphysician Practitioner (NPP)
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Complying with Medicare Signature Requirements
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Section 3.3.2.4 of the Medicare Program Integrity Manual, Chapter 3: Signature Requirements
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Section 30.6 of the Medicare Claims Processing Manual, Chapter 12: Evaluation and
Management Service Codes - General (Codes 99202–99499)
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Medicare Coverage Database
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Section 80.6 of the Medicare Benet Policy Manual, Chapter 15: Requirements for Ordering and
Following Orders for Diagnostic Tests
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Complying with Documentation Requirements for Lab Services
The Medicare Learning Network® and the Comprehensive Error Rate Testing (CERT) Part A and Part B (A/B) and
Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Outreach & Education Task Force
developed this content together to provide nationally consistent education to health care providers.
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of Health & Human Services (HHS).