Medicare update on Importance of Preparing/Maintaining Legible Medical Records

Many claim denials occur because the providers or suppliers do not submit sufficient documentation to support the service or supply billed. Frequently, this documentation is insufficient to demonstrate medical necessity. In accordance with Section 1862(a)(1)(A) of the Social Security Act, CMS must deny an item or service if it is not reasonable and necessary.(See item 1 in the "References" section below.) When determining the medical necessity of the item or service billed, Medicare's review contractors must rely on the medical documentation submitted by the provider in support of a given claim. Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS claim payment denials.

 Key Points

General Principles of Medical Record Documentation

The general principles of medical record documentation to support a service or supply billed for Medicare payment includes the following (as applicable to the specific setting/encounter):

1. Medical records should be complete and legible; and
2. Medical records should include the legible identity of the provider and the date of service.


Medicare Signature Requirements

For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature.

• If the signature is illegible or missing from the medical documentation (other than an order), the review contractor shall consider evidence in a signature log or attestation statement to determine the identity of the author of a medical record entry.

• If the signature is missing from an order, the review contractor shall disregard the order during the review of the claim (i.e., the reviewer will proceed as if the order was not received). Signature attestations are not allowable for orders