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.