Compare records to LCDs

Thursday, March 24, 2011

A. Ask Medicare payment contractors and they will tell you if the service billed is not documented in the patient's clinical record, than the service does not exist. They will further state that it is the supplier's responsibility to ensure that documentation.

Our industry doesn't typically collect clinical notes prior to billing Medicare. Not until one of the Medicare contractors associated with payment or review requests an audit, does the supplier find out that the service is not documented. This results in a denial if the claim is pre-pay, or a refund if it is post-pay.

Education of your referral source on Medicare requirements is one of the best defenses to prevent this, but it is difficult to do on a widespread basis. Self-audits are one of the next best things.

There are two types of self-audits: claim based and extrapolation. This month we'll discuss claim-based audits.

Claim based audits are simple. Select claims from either the same or different referral sources that you have a good rapport with. Choose claims that could have the most financial impact on you should Medicare conduct a review. Also, select claims that have difficult or ambiguous local coverage determination (LCD) documentation requirements. Request the medical records from all clinicians associated with the patient. Remember, for example, that a surgeon may only have the history from when the patient was referred to them. Remember to look for all documents required such as delivery tickets, AOBs, etc. After thoroughly comparing the records to the LCD, determine whether it's a clean record or if a refund is due. If it's the former, make sure it is a true refund before issuing. If you are unclear, consider consulting with your attorney or a Medicare expert. If it's the latter, there's an educational opportunity.

Remember, this is a self-audit and you are the driver.

Tom Walters is the president of Total Office Management in Columbia, S.C. Tom can be reached at 803-920-0606 or