Medicare claims and requests for additional documentation

Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D. From the June 2015 edition of AOA Focus, page 48.

In a recent review of Railroad Medicare Evaluation and Management (E&M) claims, Palmetto GBA, a Medicare contractor, had an overall claims denial rate of 54.6%. This particular review included claims for codes 99215 and 99233 (subsequent hospital care). Of the 7,545 claims reviewed, 4,766 were coded using the 99215 E&M code, and 2,650 of these claims denied netting a 54.7% denial rate on just the office visit claims.

One of the most alarming reasons for the high denial rate was a lack of provider response to the record requests, which are called Additional Documentation Requests (ADR). Providers failed to respond to the ADR an incredible 72% of the time. This failure to respond means the claims are being automatically denied.

Of the responses, approximately 12% of the claims reviewed had insufficient or incomplete documentation. Lack of signature represented 2% of those denials while approximately 10% of the claims lacked some of the record documentation elements required for the level of examination billed.

Providers are required to place a "signature for each entry which is legible and includes the provider's first and last name." Denials for lack of signature ranged from no signature to illegible signatures to illegal signatures (initials only, for example). Providers have several options for signing documentation ranging from a legal, legible signature to a signature attestation document attached when the claim is submitted.

As we have said time and again, complete documentation is required for all medical records. In the event of an ADR or a record audit, you may not change the record but can add addendums that are clearly dated and signed so a reviewer can easily determine when the information was added. Per Medicare, "All entries in the medical record must be dated, timed and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided." If the record is not complete and does not meet the documentation guidelines for the level of service billed, the claim will be denied.

Medicare and private third-party payers across the country have expressed concern about the lack of response to the ADR. Medicare has directed the carriers to continue service-specific claims reviews to ensure that services are properly documented and support medical necessity. Providers should respond quickly when records are requested, as they are often time specific in the inquiry. This type of particular "service-specific" probe will be continued due to the high denial rate caused mainly by the lack of provider response. Providers are advised that they can respond using one of several options: mail, fax and electronic submission. Medicare Carrier websites and the ADR will have specific instructions on response options. To summarize, sign your claims, complete your documentation, but most importantly, you must respond to any requests for records.