Health Information Management

News: Noridian cites 'insufficient' documentation as ICD-10 education priority

CDI Strategies, November 7, 2013

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With less than a year until ICD-10 implementation, Noridian CMS contractor for Region D, published guidance last month encouraging providers to educate physicians about the importance of complete documentation.

“One of the leading causes of payment errors for IPPS claims is ‘insufficient’ medical record documentation to support delivery of services,” the communication states.

It encourages physicians to provide documentation related to the diagnostic work-up, pain levels, and effect of the patient’s condition and pain on aspects of their daily living prior to any invasive inpatient hospital procedures.

“The record must provide sufficient details of the conservative treatment and the outcome(s) to allow the reviewer to assess adequacy of the non-invasive treatment and the medical necessity of the invasive procedure being billed,” Noridian states.



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