Getting Paid

How to Prevent a Prepayment Review From Becoming a No-Payment Review


These three documentation tips may help you avoid a Medicare claim denial.

Fam Pract Manag. 1999 Sep;06(8):14.

With Medicare conducting more and more prepayment reviews of claims for evaluation and management services, the odds of one of your claims being subject to such a review are getting better (or is that worse?) all the time. One Medicare carrier recently studied its prepayment reviews, and its preliminary findings suggest ways to prevent your claims from being denied or downcoded.

Send in the requested documentation

Of the claims denied on prepayment review, three-fourths were rejected because the practice did not submit the requested documentation — usually progress notes for the encounters in question. Admittedly, it's a hassle, but for the price of a stamp and the cost of a few photocopies you can go a long way toward ensuring payment of a claim under review.

Carefully document the exam

The carrier's data showed that one common reason for denying or down-coding claims was insufficient documentation of the exam. This often occurs when a progress note doesn't reflect the number of “bullets” (1997 guidelines) or organ systems (1994 guidelines) required for a specific level of exam. To meet this criteria, it's important to fully cover two areas for each code submission: 1. Note in the chart what you've done; 2. Verify that what you've documented is consistent with the exam level's content requirements. (For a refresher on documenting the exam, you may want to review “Exam Documentation Just Got Harder,” FPM, October 1997, and “More Help With Exam Documentation63,” FPM, November/December 1997.)

Make sure your history documentation is up to par

Insufficient documentation of history was another major reason for denying or downcoding claims when documentation was submitted. Of course, the level of history depends on the history of present illness; review of systems; and past, family and social history. You will need to review your documentation in each of these areas to ensure that your documentation of history is satisfactory. Take a good look at how you gather and update patient histories. Do your new patients fill out a thorough questionnaire? How detailed are your nurse's pre-exam questions and notes?

Also remember that while nurses or other clinical staff can record the review of systems and past, family and social history, the physician's documentation must supplement or make it clear that the physician reviewed and confirmed the information that the other staff member gathered. Taking these steps will help you to show compliance with the guidelines. (For a refresher on documenting history, see “Don't Read This Article!” FPM, February 1995, page 47.)

Document, document, document

Certainly, prepayment review of your claims is a hassle, but it doesn't have to be a losing proposition. A little attention to documenting the history and the exam and responding to requests for documentation can help to ensure you'll get paid.

Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management.


Copyright © 1999 by the American Academy of Family Physicians.
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