CMS issues guidance for handling insufficient documentation, ADRs

CMS issued change request (CR) 10778 on June 15, with an effective date of July 17, to update Chapter 12 of the Medicare Program Integrity Manual. The proposed update includes details for handling non-responders and insufficient responses to additional documentation requests (ADR) under the Comprehensive Error Rate Testing (CERT) program.

The most common cause of improper payments (accounting for 64.1% of total improper payments) during the 2016 reporting period was lack of documentation to support the services or supplies billed to Medicare, according to the Medicare-Fee-For-Service 2016 Improper Payments Report. In these instances, CERT contractor reviewers could not conclude that the billed services were actually provided, provided at the level billed, and/or medically necessary.

To clarify processes in place for the handling of insufficient documentation errors and subsequent ADRs, CMS has proposed several updates to the Medicare Program Integrity Manual, which will impact MACs and CERT review contractors responsible for determining whether claims were paid properly under Medicare coverage, coding, and billing rules.

As stipulated in the June request, CERT review contractors should respond to insufficient documentation errors by sending the billing provider or supplier, referring provider, or third-party an ADR.

If an ADR is sent and no response is received within the allotted time of 75 days, the CERT review contractor should assign Error Code 99 to the claim. Claims assigned Error Code 99 will then be posted to the Claims Status website (CSW) on the 76th day from the date the first request letter was sent and appear in the next MAC feedback batch, according to the CR.  

MACs may respond to claims submitted with Error Code 99 in one of the following ways, as stipulated in the request:

• Complete MAC feedback, prior to entering an appeal, and collect the overpayment immediately.
• Contact the provider who failed to submit requested medical records and encourage the provider to do so. MACs can allow feedback to roll over so long as they are working with the provider to obtain documentation or CERT is reviewing the claim.
• Recoup the overpayment within 10 business days prior to the deadline for entering final MAC feedback.

The request also includes guidance for handling insufficient responses to ADRs. Claims billed with documentation that is inadequate to support payment for a billed service will receive an Error Code 21 and be posted under the MAC feedback section of the CSW. MACs should contact the provider and encourage the provider to submit the requested documentation to the CERT review contractor.