Remember to Submit Complete Documentation

Once again, calls coming into APA's Managed Care HelpLine have inspired an article—this time about documentation deficits that can be corrected easily.

We recently heard from several psychiatrists in California who had been subjected to probe audits of their psychotherapy claims by Medicare and had a large percentage of their claims denied. The doctors were informed that the claims were denied on the basis of “medical necessity,” which greatly confused them because their documentation clearly established that the patients they had treated had diagnoses for which they required the psychotherapy they were receiving. Unfortunately, documentation that is missing any required element renders the service provided “not medically necessary” by Medicare definitions.

Palmetto, the Medicare administrative contractor (MAC) for California, had followed the probe audits with a request that the doctors submit corrective action plans (CAPs) stating how they would correct their future documentation. The doctors were at a loss as to what they should say in their CAPs since they were unable to discern how they could have better established the medical necessity of the treatment they provided. It was at this point that they individually called the Managed Care HelpLine for assistance.

Ellen Jaffe, the HelpLine's Medicare specialist, contacted Arthur Lurvey, M.D., the MAC medical director, to ask him to look into the problem and provide some guidance to the doctors. Dr. Lurvey had the Palmetto reviewers send him their reports and discovered that all of the claims had been rejected for reasons that might more accurately be considered as technical rather than based on medical-necessity problems.

The documentation for many of the claims had failed to provide the duration of the therapy session. This is an honest mistake, since the codes for which the psychiatrists billed (90805 and 90807) include the time in their definitions. The problem was that Palmetto's local coverage determination for these codes, which is posted on its Web site, states that documentation must include the duration of the therapy session—either face-to-face start-and-stop times or the total time. Other claims were rejected because the documentation did not include a legible signature, as required by the Centers for Medicare and Medicaid Services.

Based on past experience, Office of Healthcare Systems and Financing staff believe that the rejection of claims with these problems could be easily overturned upon appeal. Although the length of the psychotherapy session should have been included in the documentation, on appeal the case could be made that since the time is included in the code definition, the doctors had, in fact, already made the length of the session clear. As for the lack of a signature, an “attestation statement” can be submitted with the documentation, stating that the medical record for the date of the claim accurately reflects the notes the psychiatrist made in his or her capacity as physician to the beneficiary and that the information in the documentation is accurate to the best of the doctor's knowledge—followed by a legible signature and the date the attestation statement was signed (see Model Attestation Statement).

Although these were Medicare documentation problems, you would be wise to include these two elements in documentation for all of your patients because private insurers may use the same guidelines.

Some lessons learned: