The Comprehensive Error Rate Testing (CERT) program continues to identify several problematic areas with respect to providers' medical records. As a result, some Medicare Part B payments have been reduced or denied in their entirety. Findings from the CERT program are also consistent with ongoing medical review audits conducted separately by Palmetto GBA.
In order to lower the incidence of errors, the following is being published for reference. Please note that this is not an all-inclusive list but does reflect the majority of documentation issues discovered during the auditing process.
Illegible handwriting is consistently identified as the number one problem.
Legibility: All handwritten entries should be completely legible so someone other than the author or office staff is easily able to read the notation.
Patient Name: The patient's full name should be present in the notes. Along with this in the chart entries, some type of unique identification number corresponding to the Medicare patient is suggested. This is recommended as many practices have patients with similar or identical names.
Signatures in Records: Medicare requires that the individual who ordered/provided the services is clearly identified in the medical records. The signature for each entry must be legible and should include the first and last name and applicable designation, e.g., R.N., D.O., M.D. For more signature instructions and examples, we recommend reviewing the article, "Medicare Part B Medical Records: Signature Requirements, Acceptable and Unacceptable Practices".
Date of Service: Each entry's date of service should list the month, day and year.
Clinical Laboratory, Diagnostic Tests & X-rays: Valid documentation for laboratory, diagnostic and x-ray procedures must include not only the results/findings or an interpretive report, but also written evidence of the ordering-treating physician’s or NPP’s request for the procedures. Orders should be descriptive, list diagnoses, the specific procedures needed, and anatomic sites (when applicable). If a patient requires a regular regimen of testing due to a specific condition or medication, include the rationale, frequency and duration.
Generic orders requesting just 'blood work' or 'knee x-ray' alone are not acceptable. List the specific tests, number/type of views, and anatomic location.
Faxes & Chart Copies: Verify the quality of documentation being sent in response to records requests. Check the orientation (face-up or face-down) of records placed in a fax or copying machine. Frequently, we find the copies of the necessary records are of poor quality, needed portions have been 'cut off' or are completely blank.