Hi, I’m Angela James at the Centers for Medicare & Medicaid Services. Did you know that the main reason Medicare denies claims is because there’s insufficient documentation? That’s right, proper payment and sufficient documentation go hand in hand. Today, I have some pointers to help you submit documentation properly for 4 preventive services. With these preventive services, sufficient documentation is the key to proper payment. You can prevent a denial for your claim. The submitted documentation must include the following: 1. Amount of time spent providing a timed service 2. Documentation of the billed service in the medical record 3. Physician’s signature on the medical record Now, let’s talk through an example of improperly billed preventive services: A provider billed for – annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes. The provider submitted – a physician’s progress note with an illegible signature for the date of service. – a preventive care flow sheet, – a depression exam, – a nutrition exam, – a mini mental status exam. Unfortunately, the documentation didn’t include the amount of time spent on counseling. When the reviewer asked for additional documentation, the provider sent: – a signature attestation – signature log – an unsigned late entry in the margin of the medical record, dated three months after the date of service, which showed the time spent on counseling. Amendments, corrections and delayed entries in medical documentation must be clearly signed and dated upon entry into the record in keeping with PIM The reviewer scored the claim as an overpayment and the Medicare Administrative Contractor (MAC) recouped payment. So, how can the provider make it right? – If you’re providing a timed service, record the start and stop times, or the total time spent – Sign entries in medical records at the time of service; and – Learn about the non-covered indications and frequency limits for preventive services. If you need an attestation for an illegible signature, you can download a sample on the CERT provider website at www.certprovider.com Now, this short video is an overview of the main points you need to know about billing for some preventive services. To learn more, search for “preventive services” on cms.gov and read the National Coverage Determinations and Program Integrity Manual.