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May 29, 2026

Insufficient Documentation Errors

Insufficient documentation is among the top 4 Comprehensive Error Rate Testing (CERT) review errors. Provider or hospital medical records must include sufficient documentation to verify that the services performed were reasonable, necessary, and required the billed level of care. When documentation is missing or incomplete, there's no justification for payment of the services or level of care billed to Medicare. As a result, the CERT review contractor (RC) determines that an overpayment exists, and the reviewed claim payment is recouped (partial or in full).

When submitting medical records to the CERT RC, gather all documentation relevant to the services billed. Make sure each document is complete, legible, and signed.

Documentation should include:

  • Reason for encounter, relevant history, exam findings, test results, and date of service
    • Document in the office and/or hospital records each time a service is provided.
  • Assessment and impression of diagnosis
  • Plan of care with date and legible identity of observer
  • When providing concurrent care for hospital or custodial care facility patients, each physician should identify his/her specialty where it helps to support medical necessity.
  • Progress notes for hospital or custodial care facility patients; the provider who examined the patient should sign and date each entry.
  • Medical information should be clear, concise, and accurately describe the patient's condition.
  • Documentation to support that the rendering or billing provider reported on the claim is the healthcare professional who provided the service
  • Documentation with statements like "same as above" or ditto marks (") isn't acceptable.

Documentation for diagnostic services should include:

  • An order (i.e., communication from the referring or treating physician) to perform a specific test for the patient. The order may also include an additional diagnostic test if the rendering or treating physician deems necessary based on the initial test results.
    • The order can be a written document signed by the referring or treating physician that is hand-delivered or faxed to the testing facility.
    • A signature isn't required for physician pathology services or clinical diagnostic tests that are paid based on the clinical laboratory or physician fee schedules.
    • If the order is communicated by phone, both the testing facility and the referring or treating physician must document the call in the patient's medical record. Although a physician's order doesn't require a signature, the physician must clearly document his/her intent to order the test.

If CERT requests documentation for a diagnostic service, the testing facility must obtain the referring or treating physician's progress notes to support medical necessity for the ordered service.

When requested, the medical record documentation you submit must allow any medical review contractor, including CERT, to:

  • Verify the rendering physician or practitioner for each service billed to Medicare.
  • Substantiate both the services and level of care performed and billed.

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