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Medical Coding News Archives

Documents Used by Review Contractors

April 19, 2013:

Karen H. Kachur, RN, CPC

Review contractors have historically used any documentation in support of prepayment and postpayment determinations. However, new directives added to the Medicare Program Integrity Manual, chapter 3, section, are now in place regarding guidelines for documentation to be used by review contractors as well as specific definitions of each of those review documents.

Review contractors are now required to take all of the permanent medical record entries made by physicians, treating practitioners, and licensed/certified medical professionals under consideration for review to obtain useful information applicable to the claim.

Contractors may not, however, consider Certificates of Medical Necessity (CMN), DME Information Forms (DIF), physician verification, or statements from suppliers in the absence of additional review information, even if it is signed by the physician ordering the service. Review contractors are also now required to confirm that the physician or other provider does not have a financial relationship with the supplier for coverage of DMEPOS.

The following definitions apply:

Progress Notes: Include visit, office, and encounter notes, documentation of evaluation and management service, face-to-face evaluation notes, or any other record of the service provided by a physician or other licensed/certified medical professional in the medical record. Progress notes may be in any form or format including hardcopy and electronic.

Template: A paper or electronic tool or instrument/interface that aids in documenting a progress note.

Electronic Records: Include any type of interface including but not limited to:

  • Simple electronic documents
  • Sophisticated graphical user interfaces (GUIs) with clinical decision and documentation support prompts
  • Electronic pen capture devices

Licensed/Certified Medical Professional (LCMP) : Medical professional licensed or certified to practice in the state in which services are provided.

Physicians and LCMPs are not allowed to have financial relationships with suppliers of DMEPOS.

Although CMS does not prohibit the use of any templates, the agency also does not approve or endorse any specific type. CMS does, however, discourage the use of templates with few options and/or space for information including the use of check boxes, predefined answers, limited space for information, etc. as this type of template does not allow for reporting of adequate details in the clinical information to prove requirements for coding and coverage have been met.

If a physician/LCMP decides use a template during an encounter, CMS encourages the use of a template which allows for documentation of a comprehensive amount of information adequate to validate that applicable coverage and coding criteria were met.


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