tci Medicare Compliance & Reimbursement - 2011 Issue 3

Physician Notes: Missing Physician Signature Could Lead to Unpaid Claims

The old saying, "If it wasn't documented, it wasn't done" has taken on a whole new meaning at one MAC. Highmark Medicare Services, the Part B carrier for six states, recently listed the CERT errors that it found during a random claims check between July and September of 2010. Highmark found that 18 out of 52 errors weredue to insufficient documentation and 29 were due to incorrect coding. The majority of the errors for insufficient documentation were related to the fact that the medical record documentation did not contain a valid physician's signature or the radiology report/diagnostic test did...

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