Awareness : OBC Tips

Reducing Improper Medicare Payments

Insufficient documentation means that something is missing from the medical record. Claims are determined to have insufficient documentation errors when the documentation is inadequate to support the service billed.

  • No documentation to adequately describe the service defined by the HCPCS code or HCPCS modifier billed
  • Missing a legible identifier
  • Not having signature on a procedure note or progress note No diagnostic test result
  • No signature log or attestation submitted when physician signature was missing and records were requested
  • Missing procedure note
  • No documentation of the medical necessity for the procedure