Insufficient documentation means something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for diagnostic testing services.
Physician order
or intent to order: The physician who is treating the beneficiary must order all the diagnostic tests. The treating physician is a physician who furnishes the consultation or treats the beneficiary for a specific medical problem and uses the results in the management of the specific medical problem. The progress notes should clearly indicate all tests to be performed. The documentation to support the intent to order would be a signed progress note, signed office visit note, or signed physician order.
Medical necessity: Documentation in the patient’s medical record must support the medical necessity for ordering the diagnostic service per Medicare regulation and applicable national coverage determinations (NCD).
Keep these medical records available upon request:
