Medicare Audit/Record Request Tips

Tips for Responding to Record Requests

Pretend YOU Are The Reviewer

Pretend you know nothing about your individual office and probably have a stack of claims to get through by the end of the day: 
Are you more likely to approve a claim that is easily readable and quick to look at and understand, or one that requires an hour of your time to decipher?

Read the Letter

  • Make sure you read the letter carefully and include everything it requests. 
  • If it is asking for a certain date(s) of service (DOS), make sure you send in the notes for that DOS and all related information—including all information from the initial date of service, the most recent exam, history, treatment plan, and any diagnostic findings.  
  • All these items help a reviewer place the pertinent DOS in a larger context.

Consider Attaching a Brief Note/Cover Letter

  • Consider attaching a brief note/cover letter to the front of the requested information, if you have details of the patient’s history spread out over several years. 
  • The letter could explain that you have seen the patient off and on for “x” years, so the history has been updated over time—then provide a brief summary of when and what has changed with the patient.  
  • Note: Such a cover letter is not a substitute for the actual documentation, but it will make the reviewer's job easier and help you overall.

Make Sure Your Notes Are Clear

  • Make sure your notes can be read and understood by someone other than you or your office staff.  
  • If you think someone else might have trouble reading your documentation, submit a transcribed copy along with the original documentation.  
  • If you use different colored ink for documentation, and it is necessary for accurate interpretation, make color copies.  
  • If you use non-standard abbreviations, make sure you include a legend with your records.  
  • Also, be sure to check your copies and make sure nothing has been cut off the edges/margins. If your record is larger than the standard 8-½ x 11, make sure copies are the same size as your official record.

Work with the Contractor

  • As much as possible, try to work with your Medicare Administrative Contractor  and be willing to provide further documentation and answer questions. 
  • Remember, third-party payors have a right to ensure their money is being spent appropriately, and asking for your documentation is one way of ensuring this.  This can be a beneficial experience for all parties if everyone takes away something positive.

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Make Sure Your Documentation Is “Up to Snuff”

  • According to the OIG report released June 2005, 94% of the documentation reviewed was missing one or more required elements.  
  • Make sure you are including details when documenting examinations, histories, treatment plans, and diagnostic findings.

Perform A Self-Audit

  • A self-audit is an examination performed both by and within a given health care practice which generally focus on reviewing bills and medical records to assess, correct and maintain compliance with applicable coding, billing, and documentation requirements. 
  • Review the “Tips for Responding to Record Requests” (see above) and ask yourself if your records would be ready if you received a request tomorrow.  
  • Consider checking your documentation for readability and completeness.

Make Corrections/Additions Where Necessary

  • Review your records and see if they pass the test.  
  • If you discover shortcomings, do not change any current records.  
  • Instead, note any additions and/or corrections with the current date (and be sure to sign/initial them).  Keep a “memo for record” that you conducted an internal review and found these outlined problems.  This shows good faith and due diligence on your part as a practitioner.

What Else Can You Do?

Download and Review your Current Local Coverage Determination (LCD)

  • First and foremost, make sure you closely review and are following your LCD, available from your Medicare Administrative Contractor (MAC)
  • The LCD typically includes:
    • A description of each covered service;
    • Documentation requirements;
    • Diagnosis codes that support medical necessity;
    • Guidance to assist providers in submitting correct claims; and
    • An outline of how the MAC will review claims to ensure that the services provided meet Medicare coverage requirements.
  • It is particularly important to access your LCD if your area has recently changed MACs or---make sure you are up-to-date on the current LCD.

Don’t Panic!!

  • Spend some time upfront and you can avoid headaches further down the road.  
  • “Wisdom is knowing what to do next; virtue is doing it.” (David Starr Jordan)

Learn About What’s Happening

The ACA Recommends Reviewing the Following Resources Offered by the Centers for Medicare and Medicaid Services (CMS):