Hemodialysis Treatment
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 hemodialysis treatments:
- Missing physician order for treatment;
- Missing documentation to support the treatment;
- Missing signature of staff providing dialysis treatment;
Physician order: The hemodialysis order must include the prescription, duration and frequency of treatments.
Supportive documentation: The documentation to support the hemodialysis treatment includes, the interdisciplinary patient assessment, dialysis plan of care, physician monthly assessment notes, laboratory orders and results, medication orders and administration record, nurses monthly progress note, treatment notes.
Signatures: Signature of staff providing dialysis treatment.
Related Content
- CMS IOM Publications:
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- 100-02, Medicare Benefit Policy Manual, Chapter 11, Section 50A (ESRD Prospective Payment System Base Rate)
- 100-04, Medicare Claims Processing Manual, Chapter 8, Section 10 (General Description of ESRD Payment and Consolidated Billing Requirements)
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- 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1.1 (Progress Notes and Templates)
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- 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements)