CMS Reminder: The Importance of Proper Documentation
Sonal Patel, BA, CPMA, CPC, CMC, ICDCM
![Sonal Patel, BA, CPMA, CPC, CMC, ICDCM]()
Sonal Patel, BA, CPMA, CPC, CMC, ICDCM
? CEO & Principal Strategist ? Healthcare Coding Advisor ? Auditor ? Compliance Consultant ? Author ? Educator ? Speaker ? Podcast Creator and Host for the Paint The Medical Picture Podcast series
On April 11, 2019, CMS released a gentle reminder on why proper documentation is necessary.
Criteria for proper documentation:
- Communicates the who, what, when, where, why, and how to all patient caregivers
- Ensures patients are receiving services, or gets items that are reasonable and necessary
- Verifies that are all services rendered and items furnished are medically necessary
- Supports accuracy of claims payment, the first time
- Supports favorable medical review decisions (and reduces the costs of administrative appeals)
Top Error, According to Comprehensive Error Rate Testing (CERT) Program:
- Insufficient documentation
- (DOES NOT mean documentation does not exist)
- (DOES MEAN something was incomplete or missing from documentation submitted with claim)
2. Medical Necessity
3. Incorrect Coding
4. Other
5. No Documentation
Consequences of Improper Documentation:
- Loss of financial revenue
- Patient care errors