Clinical documentation: Defend yourself with documentation

Q. What’s the risk associated with not obtaining clinical documentation?
Friday, December 20, 2013

A. It is probably the main area where DME suppliers are most vulnerable. In an audit situation, documentation is your only defense. If you are waiting until you get audited to get the documentation, chances are,  it’s too late. Auditors are precluded from considering any documentation dated after the date of service in question because medical necessity must be established before providing the equipment. Therefore, the immediate risk is with claim denials.

An even greater risk is associated with claims that have a KX modifier requirement. In most cases, the policies state that a supplier should put a KX modifier on a claim only if all of the coverage criteria in the “Indications and Limitations of Coverage and or Medical Necessity” section of the policy have been met. How would one know that if they don’t have the documentation? If a company is audited on claims with a KX modifier and they either don’t have the documentation or it doesn’t reflect that the coverage criteria has been met, they are at risk for false-claim violations which carry a penalty of $11,000 per false claim. I think the government is using the KX modifier as a tool to implement these penalties.

Lastly, in this current audit environment, CMS is encouraging contractors to extrapolate overpayments for suppliers. So, they can review just a small sample of claims and then project that overpayment to your entire universe of claims. This results in large multi-million dollar overpayments due to insufficient or missing documentation that you will have to defend through the appeal process. In the meantime, you’ll have to develop a plan to refund the money.

Wayne van Halem is president of The van Halem Group. Reach him at 404-343-1815 or