Health Information Management

Address insufficient documentation to prepare for RACs

HIM-HIPAA Insider, October 5, 2010

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As providers navigate their way through complex reviews and the newly approved medical necessity audits, keeping vulnerabilities such as insufficient documentation in mind is paramount.

CMS reiterates the importance of this in Medlearn Matters article SE1024—the first in a series of
articles regarding RAC high-dollar improper payment vulnerabilities. In its publication, CMS reminds providers that medical documentation must be submitted within 45 days of the date of the Additional Documentation Request (ADR) letter. Failure to submit medical records within this time frame will result in a denial unless an extension has been granted.
RACs must initiate one additional contact with providers before issuing a denial for failure to submit documentation. RACs also must accept and review extension requests if providers are unable to submit documentation in a timely manner. Deadlines for submission must be clearly stated in all RAC ADR letters. RACs also must indicate the status of a provider’s additional documentation requests on their claim status websites and establish a provider Web portal so providers can customize their address and establish a contact to receive all ADR letters.
Hospitals should address insufficient documentation if they haven’t already done so, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK. “A good clinical documentation program is probably the hospital’s best defense.”
Editor’s note: This tip was adapted from an article in the October issue of Briefings on Coding Compliance Strategies.

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