We are working with the AMA to revise our documentation guidelines in a way that is consistent with the AMA's codes. We and the AMA want physicians to know how to document those elements in the medical record that will justify billing under the appropriate code. Moreover, physicians order most other medical services. There is no question that we must require physicians to properly document the care that taxpayers pay for. It is essential not just to fight waste, fraud and abuse.
Proper documentation is also a key part of providing quality care.
Unfortunately, proper documentation is often lacking. The first-ever comprehensive audit of Medicare, done under the Chief Financial Officers Act in 1996, shows that nearly half of inappropriate payments by Medicare involve insufficient documentation to tell whether the claim is appropriate or whether the care is medically necessary. Twenty two percent of these inappropriate payments were to physicians, and more than half of these inappropriate payments to physicians were improper because the physician did not have adequate documentation. We have completed reviews of claims from the first quarter of this fiscal year, and preliminary results are disturbing. They suggest that documentation is woefully inadequate and does not support three out of every five claims submitted to us.