Q&A: Highlighted areas on documentation leading to denials

Q: We have received some denials of services due to “illegible” or missing authentications and documentation. We still have some handwritten documentation that gets scanned into our electronic health record. When we look at the original document, sometimes the physician’s office staff has highlighted where they want the physician to sign, but when we scan it, it is obliterated in the scan. This is causing us to lose reimbursement as the CERT and our MAC (National Government Services) is denying it as missing documentation.

A: This is a common issue with highlighting on a record. When the documentation is scanned into an electronic record or a copy is made, the “highlight” is no longer the easy-to-read yellow, but turns black and you cannot see the documentation or the authentication. From the MAC and CERT perspective, the documentation doesn’t exist or is considered illegible. They deny or recoup the reimbursement because the service billed is not supported in the official, legal record. This is not a specific requirement for the MAC and CERT program, as other insurance carriers and payers require the same supporting documentation.

Work with your physician offices to use the “flags” for signatures and documentation rather than highlighters. They can’t “see” the impact as what they sent you was legible. Show them an example of what happens when you scan the information into your electronic record. Request that they use the flags rather than the highlighters. Don’t accept an order or documentation as valid if there are highlighted areas. This could be considered an incomplete physician order by the time it gets into your electronic record. Encourage them to utilize electronic order entry, or put these into your electronic order entry and then have the physician/practitioner authenticate the order electronically.

The provider of service is the accountable and responsible party for ensuring the documentation to support the service is legible and available. So, in this instance, it falls into the facility provider’s responsibility to insure that everything is available and legible.

National Government Services (NGS) provides a specific list of documentation responsibilities for submitting records for review to NGS or to the CERT. You can apply this list for either professional claims/records or facility provider claims/records, as well as for other payers. Below is an excerpt from the NGS website (other MACs have similar documentation on their websites):

• Documentation is legible including the physician’s signature and no highlighting is used on medical records
• Records are for all services and dates of service on the claim
• The medical records submitted provide proof that the service(s) was ordered, rendered by the medical doctor (MD) or appropriate nonphysician provider, and provide justification to support the medical necessity

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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