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Comprehensive Error Rate Testing

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Surgery Services

Insufficient documentation means that 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 surgery: 

  • Missing operative report
  • Missing documentation that supports the need for the surgical procedure
  • Missing electronic signature or legible signature of the performing provider

Operative report: The signed operative report must be submitted supporting the surgery was performed.

Documentation supporting the need for the surgery: Medical documentation supporting the medical necessity for the surgery (e.g. previous office visit notes or a consultation report) must be submitted.

Signature: An electronic signature or legible signature is required on medical records.

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