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Comments concerning a Medicare audit, submitted by Samuel A. Nigro, M.D.

These are the first five pages of a 15-page article by Dr. Nigro. They concern Dr. Nigro's analysis of the Medicare Policy Manuel concerning documentation of services. The remainder of the article, not uploaded here, concerns Dr. Nigro's opinion of the process, ways to fight Medicare abuses, and sample letters to patients. We have not assessed the effectiveness of the suggested techniques.


By: Samuel A. Nigro, M.D.

Chief Psychiatrist, The Noosphere Center,

St. Vincent Charity Hospital, Cleveland, OH Asst. Clinical Professor of Child Psychiatry, Case Western Reserve University and University Hospitals of Cleveland


February, 1998


Doctrine once sown strikes deep its root, and respect for antiquity influences all men. Still the dye is cast, and my trust is in my love of truth and the candor of cultivated minds.

    William Harvey, Preamble to his Treatise on the Circulation of Blood

Undergoing a Medicare audit is an intimidating event. Mine is in process, but I have already been assessed for alleged failure to document services. In my efforts to investigate, I reviewed the Medicare Policy Manual DOC-1 -- a one-page, eight-paragraph statement entitled "DOCUMENTATION OF SERVICES." This page should be of interest to all medical practitioners who are still working or plan to work with Medicare.

In the Medicare Policy Manual which contains the controlling policies medical providers must follow, there are no substitutes, modifications, exceptions, elaborations, or qualifications related to Documentation of Services. What follows is a paragraph-by-paragraph analysis:

Medicare carriers conduct audits of processed claims. Such audits include a review of patients' medical records for documentation verifying that services were medically necessary and that the services were rendered as billed on the claims. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 1, Rev. 3/97.)

This seems straightforward enough, but these words contain hidden meanings only understood after reflecting on the remaining paragraphs:

There must be documentation to support each service billed. Usually, such documentation will be found in physician's orders and progress notes, operative reports, test results, etc. Illegible documentation is of no value in verifying medical necessity or coding accuracy for services billed. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 2, Rev. 3/97.)

The first sentence of paragraph 2 clearly indicates that the documentation must support each service billed. It does not say "exhaustively confirm," "comprehensively outline," "thoroughly detail," or "prove" but support each service billed. However, "exhaustive confirmation" and the like are exactly what Medicare auditors require when referencing an alleged failure to follow Documentation of Services.

Sentence 2 of paragraph 2 clearly indicates that the documentation described involves the total chart. No specific piece of the chart is to be taken as the final determinant for documentation. Rather, Medicare reviewers must review and accept the entire chart to determine Documentation of Services. However, Medicare reviewers are alleging failure to document services without reviewing the total chart.

The third sentence of paragraph 2 about "illegible documentation" stands without need for elaboration, except for a question about "illegible" to whom. An initial note thought illegible suddenly may become easily more readable as the reader becomes adjusted to the provider's cursive script.

The third paragraph refers to evidence of a physician visit:

Even though hospitals or other facilities may not require daily record entries by physicians, Medicare regulations do require evidence of each visit by physicians. See Miscellaneous Section, Span Coding. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 3, Rev. 3/97.)

It is very clear that the precise absolute attendance of the physician is expected. However, there is no specific statement that the evidence of presence needs to be comprehensive, exhaustive, overwhelming, full, or bibliographic. But Medicare reviewers do demand extraordinary evidence of a physician's presence when alleging a failure to document services.

With respect to the fourth paragraph detailing Documentation of Services, it states:

Lack of documentation could be considered fraud or abuse that is subject to monetary penalties, imprisonment, and/or exclusion from participation in the Medicare program. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 4, Rev. 3/97.)

There is room to wonder about a precise meaning of "lack" for these purposes. There is room for the accusation of "ambiguity" but most likely, a reasonable man's understanding of such would be difficult to deny.

At this point, the Documentation of Services page has a central heading stating: "VERIFYING MEDICAL NEED". The last four paragraphs are subsumed under this major category.

Medicare makes payment for services related to the "diagnosis and treatment of an illness or injury. Documentation for such services means written information confirming the degree of medical problems. This could include the patient's history, examination and/or test results, symptoms and complaints. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 5, Rev. 3/97.)

The "written information" obviously refers to the entire chart. No specific requirements are identified but only a list of what the information "could" include. "Could include" is a far cry from "must include" or "shall include." Thus far, the only "must" in documentation is direct evidence of presence of the provider.

In most cases, diagnosis codes (ICD-9-CM) appearing on the claim will suffice as documentation for medical services. However, there are situations where additional information is necessary. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 6, Rev. 3/97.)

This seems straight forward enough. The diagnosis code will suffice as documentation except as described in paragraph 7.

Procedures identified by an "unlisted procedure" CPT code require a description of the service performed. This information may be submitted via fax for electronic billers or a brief statement indicating how the procedure was "unusual" may be included in the documentation record for claims submitted electronically. If modifier 22 is indicated on the claim, an operative report and a concise statement about how the services differ from the usual must be submitted. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 7, Rev. 3/97.)

Paragraph 7 describes those "situations where additional information is necessary" when a diagnosis code alone does not suffice as documentation for medical services. Obviously, listed procedure codes stand alone without need for additional information.

Acceptable documentation of medical need is that which is prepared by one physician and may be easily evaluated by another physician. (Medicare Policy Manual, DOC-1, "Documentation of Services", Para. 8, Rev. 3/97.)

Paragraph 8 provides the only definition of "acceptable" documentation. Acceptable documentation is that written by a physician and certified by another physician to be easily evaluated. The policy manuals do not say that it must be easily evaluated by "all" physicians or "certain" physicians, but only "another" physician. There is no mention at all of "non-medical" reviewers determining acceptability of documentation.

Summary of DOC-1

(1) Documentation is needed to support services provided. Documentation is not needed to prove the services provided.

(2) The entire chart is part of the documentation. Documentation is not limited to the notes of the service.

(3) Evidence of each visit must be present. Documentation of the visit as a direct presence of the provider is absolute.

(4) Medicare is to pay for services relating to "diagnosis and treatment of an illness or injury" within the context of the entire medical record. Documentation decisions cannot be made without review of the entire medical record and all parts of the record can be used to document a service.

(5) The diagnosis code (ICD9-CM) will suffice as documentation except for an "unlisted procedure." No other procedure than an "unlisted" one requires a description of the service performed.

(6) Acceptability of documentation is confined to the assertion of easy evaluation by another physician. No documentation is acceptable unless so asserted as "easily evaluated" by another physician. Only physicians can determine "acceptability."

(7) A precise restatement of the first paragraph of DOC-1, quoted above, may now be offered: Audits of processed claims are to be based on (1) review of the patients' medical records pertinent to a specific diagnosis code(s); (2) seeking therein assertions by another physician that the record is easily evaluated; and (3) that proof is present of the direct involvement of the provider.

Medicare reviewers and auditors have gone far beyond their controlling policies when alleging a provider has failed to document services. While it is standard for guidelines and instructions to accompany government regulations, the administrative details must be in conformity with the controlling articulated policies. Such does not appear to be the case with Medicare. It would appear that Medicare has been exposed, and the text of DOC-1 will not support the actions of Medicare and its far-flung misrepresentations. Any conclusions to the contrary need to be based on other parts of the Medicare Policy Manuals.