LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-11 SE1237 Legible Medical Records

MLN Matters®
Number: SE1237 Related Change Request (CR) #: N/A
Related CR Release Date: N/A Effective Date: N/A
Related CR Transmittal #: N/A Implementation Date: N/A
Importance of Preparing/Maintaining Legible Medical Records
Provider Types Affected
This MLN Matters® Article Special Edition (SE) is intended for physicians and other providers who document treatment for Medicare beneficiaries and/or submit claims for Medicare Fee-For-Service (FFS) reimbursement.

  • Provider Action Needed
    The Centers for Medicare & Medicaid Services (CMS) is publishing this article to highlight the importance of legible documentation in avoiding claim denials. This SE1237 article is informational only and does not alter existing Medicare policy, and does not introduce new policy.
  • Background
    Many claim denials occur because the providers or suppliers do not submit sufficient documentation to support the service or supply billed. Frequently, this documentation is insufficient to demonstrate medical necessity. In accordance with Section 1862(a)(1)(A) of the Social Security Act, CMS must deny an item or service if it is not reasonable and necessary.(See item 1 in the “References” section below.) When determining the medical necessity of the item or service billed, Medicare’s review contractors must rely on the medical documentation submitted by the provider in support of a given claim. Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS claim payment denials. (See item 2 in the “References” section below.)
  • Key Points
    The general principles of medical record documentation to support a service or supply billed for Medicare payment includes the following (as applicable to the specific setting/encounter):
    General Principles of Medical Record Documentation (See items 3,4,5 in the “References” section below.) —Be Aware
    1. Medical records should be complete and legible; and
    2. Medical records should include the legible identity of the provider and the date of service.
    Documents containing amendments, corrections, or delayed entries must employ the following widely accepted record keeping principles: Amendments, Corrections and Delayed Entries in Medical Documentation (See item 6 in the “References” section below.)
    1. Clearly and permanently identify any amendments, corrections or addenda.
    2. Clearly indicate the date and author of any amendments, corrections, or addenda.
    3. Clearly identify all original content (do not delete).
    For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature.
  • Medicare Signature Requirements (See item 7 in the “References” section below.)
    If the signature is illegible or missing from the medical documentation (other than an order) the review contractor shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.
    If the signature is missing from an order, the review contractor shall disregard the order during the review of the claim (i.e., the reviewer will proceed as if the order was not received).
    Signature attestations are not allowable for orders.
  • Main Reference-CLICK-HERE