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Medicare Documentation

Simply stated, Medicare documentation is the key to a quality driven, results achieving, compliant and successful business.  This applies to DME providers, physicians, home health agencies, long term care facilities, or any Medicare approved supplier.  Most Medicare claims that are denied are denied due to issues related to Medicare documentation errors.


Medicare states that the Medicare documentation, “should be of such content and clarity as to make it abundantly clear to any third-party reviewer, the patient’s symptoms, history, physical findings, and plan of treatment…or the claim will be denied as not be medically necessary.”


Additionally, at a high level, Medicare documentation should meet all of the following expectations:

  1. All Medicare documentation should be complete, legible, signed and dated

  2. Medicare documentation is the recording of pertinent facts of and observations about an individual’s health history, including past and present illness, test results, treatment and outcomes.

  3. The Medicare documentation of each patient encounter should include: the date, the reason for the encounter, appropriate history and physical exam, review of lab results, x-ray results, other ancillary services (where appropriate) assessment, and plan of treatment

  4. If your billing codes are time based, then the Medicare documentation must clearly and accurately notate how much time was spent with the Medicare beneficiary.

  5. If your billing for E/M services, you need to be sure that your Medicare documentation includes History of Present illness (HPI), Review of Symptoms (ROS), and Past Medical, Family, and Social History (PFSH)

  6. Your Medicare documentation should clearly and accurately include the proper ICD-10’s that are required for treatment, testing, and payment

  7. Your modifiers, if appropriate, should reflect what story the Medicare documentation tells


Medicare documentation authors need to become better story tellers.  Time after time we have discussions with health care professionals and their Medicare documentation makes perfect clinical sense to them.  The problem arises due to two equally important dynamics:

  1. Medicare, and many other payors, have made the decision that they want to insert themselves into medical assessments, treatment plans, and who, what and when certain services or products are appropriate and when they are not; AND

  2. Due to Medicare denial rates increasing, Medicare audits are increasing and now it is required that Medicare documentation be written for non-clinical reviewers to make decisions regarding medical necessity.

AND remember this key expectation Medicare has placed on Medicare documentation;

“Medicare documentation should be of such content and clarity as to make it abundantly clear to any third-party reviewer, the patient’s symptoms, history, physical findings, and plan of treatment…or the claim will be denied as not be medically necessary.”

This now forces Medicare documentation authors to be GREAT story tellers. Most of the Medicare documentation that we review is incomplete.  It may tell us when and to whom a procedure, treatment, or product was provided, but now we must also include in the Medicare documentation how, why, and what other treatments were considered, who else was consulted, what is the goal of the treatment selected is and Medicare documentation that also tracks the progress of the treatment plan and if the treatment plan is working or not.  Authors of Medicare documentation do not need to write the Moby Dick version of Medicare documentation, but they MUST meet all the requirements and provide more than just crib note versions of the encounter.

While this is a slippery slope we have entered, do not underestimate the fact that Medicare ADR’s, TPE Audits, CERT Audits, RAC audits, and especially, UPIC audits are here to stay and the ONLY WAY to win these audits is to be 100% committed to providing or obtaining compliant Medicare documentation.

Due to the continued increase in Medicare audits, Medicare documentation is more critical than ever.  It has become a key to quality/key to compliance core element that requires business owners and executives to ensure they have the following in place:

  1. Strong understanding of what LCD’s and policy articles apply to their business and set forth the Medicare documentation requirements

  2. Become familiar with Medicare Documentation checklist(s)

  3. Kept abreast of Medicare documentation requirement changes

  4. Medicare documentation policies and procedures that allow for information and knowledge to flow throughout the organization

  5. Medicare documentation policies and procedures that drive training, knowledge and expertise to key areas involved in Medicare documentation

  6. Quality control measures that ensure nothing ships and/or bills without the Medicare documentation requirements being met.


There is a TON to know and manage, however, Boost Advisory Group is here to help you every step of the way.  We offer the following services regarding Medicare documentation:

  1. Medicare documentation training services

  2. Medicare documentation requirement updates

  3. Medicare documentation outreach services

  4. Medicare documentation process and operational consulting

  5. Medicare documentation compliance reviews

  6. Medicare appeals 

  7. Medicare audit preparation services

  8. Medicare audit response services

  9. Medicare compliance plans


When it comes to Medicare documentation, Boost Advisory Group has you covered.

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Boost Advisory Group are experts in DME consulting, DME revenue optimization, Brightree consulting and optimization, DME business process outsourcing, Medicare TPE, RAC, and UPIC audit response services, executive coaching, operational development, Analytics and reporting optimization to improve topline and bottom line. We are experts in helping our clients grow their business by reaching operational and financial excellence.

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