Medicare tweaks documentation process

Friday, May 24, 2013

WASHINGTON – Three recent changes to the Program Integrity Manual could give providers some relief from common documentation woes, say industry attorneys.

At the top of the list: a clarification of CMS’s policy on templates.

“CMS does not prohibit the use of templates to facilitate record-keeping,” reads the new language in the manual, published in March.

Other clarifying language addresses attestations and physician responsibility.


Providers have been conflicted about the use of templates and forms to help physicians document the information needed to qualify a patient for HME, since many of these tools haven’t held up under CMS’s scrutiny. They should still be cautious, says Edward Vishnevetsky, an associate with Munsch Hardt in Dallas.

“The template cannot take the place of the physician’s documentation,” he said. “It can be a blueprint for a physician to know what to address, but you need the clinical documentation to support what’s in the template.”


Attorney Neil Caesar says language allowing physician attestations for clinical issues that are not adequately documented in the progress notes is a “huge improvement.”

“CMS has taken a dim view of anything that altered the record, even if that alteration was remedial,” said Caesar, president of the Health Law Center in Greenville, S.C. “Allowing physicians to add things will benefit all suppliers.”

Still, attestations can’t justify medical necessity by themselves, and providers should try to fill in documentation gaps as soon as possible, says Denise Fletcher, an attorney with Amarillo, Texas-based Brown & Fortunato.

“It has to be contemporaneous with the provision of the equipment—how would the doctor remember seeing the patient two years later?” she said. “This could be a valuable tool, but if you’re too far removed, it won’t be effective.”

Physician responsibility

New language in the manual also makes doctors responsible for providing patient records. If they don’t provide those records, they could face a MAC or RAC review, the manual states.

While Fletcher is unsure of how this will be enforced, it has the potential to provide extra leverage for providers struggling to get the documentation they need. 

“It could be a chance for providers to say, ‘You have to give us the records, and here’s why,’” she said.