06/17/2025

ASCO's Coding Tip of the Month

The Centers for Medicare and Medicaid Services recently updated their Fact Sheet “Complying with Medical Record Documentation Requirements.” Updated language reiterates that sufficient documentation in the provider records “must verify that services performed were compliant with CMS policies and required the level of care billed”. In fact, CMS found in that insufficient documentation was the cause of 59.8% of all improper payments made by Medicare in 2024. 

Documentation insufficiencies, particularly for office visits, may result from errors such as: the documentation not supporting the reported level of service, failure to meet the signature requirements for payment, or inadequate documentation for the billed date of service.

When medical records are requested, it is the responsibility of the billing provider to submit the requested documentation. Lack of proper or complete documentation can invalidate the services reported, potentially resulting in claim denials or overpayment issues.