Insufficient medical record documentation is pervasive in the medical community regardless of healthcare setting or clinician. This environment of persistent insufficiency in clinical documentation exists for a variety of reasons, a major contributing factor being the increased use of the electronic health record mandated by Medicare under meaningful use. The electronic health record’s current structure and format is simply not conducive to capturing the physician’s clinical judgment, medical decision making, thought processes and problem solving capabilities in a clear, logical fashion in support of evidence based medicine and smart effective care choices.

Insufficient clinical documentation contributes to outside reviewers second guessing physician’s clinical judgment and appropriateness of admission decision, inpatient versus observation, under the Medicare 2 midnight rule or providing and/or ordering of any healthcare service. The Comprehensive Error Rate Testing (CERT) program was established by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claim payment in the Medicare Fee-For-Service (FFS) Program.

The intent of the CERT program is to protect the Medicare Trust Fund by identifying errors and assessing error rates, at both the national and regional levels. Findings from the CERT program are used to identify trends that are driving the errors, such as errors by a specific provider type or service, and assist with allocation of future program integrity resources. The CERT error rate is also used by CMS to evaluate the performance of Medicare contractors.

The fiscal year (FY) 2014 Medicare FFS program improper payment rate is 12.7 percent, representing $45.8 billion in improper payments, compared to the FY 2013 improper payment rate of 10.1 percent or $36.0 billion in improper payments (1). The table below outlines the improper payment rate and projected improper payment amount by claim type for FY 2014. The reporting period for this improper payment rate is July 1, 2012 -June 30, 2013.

Service Type Improper Payment Rate Improper Payment Amount
Inpatient Hospitals 9.2% $10.4B
Durable Medical Equipment 53.1% $5.1B
Physician/Lab/Ambulance 12.1% $11.0B
Non-Inpatient Hospital Facilities 13.1% $19.2B
Overall 12.7% $45.8B


Notice the inpatient hospital and Physician/Lab/Ambulance service types account for 48.8% of the total improper payment amount


CERT Error Categories

Let’s take a look at designated error categories by type to gain a sense of understanding of common themes and patterns of “improper payment” designations.


  • No documentation– Claims are placed into this category when either the provider or supplier fails to respond to repeated requests for the medical records or the provider or supplier responds that they do not have the requested documentation.


  • Insufficient Documentation- Claims are placed into this category when the medical documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.


  • Medical Necessity- Claims are placed into this category when the CERT contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage policies.


  • Incorrect Coding- Claims are placed into this category when the provider or supplier submits medical documentation supporting (1) a different code than that billed, (2) that the service was performed by someone other than the billing provider or supplier, (3) that the billed service was unbundled, or (4) that a beneficiary was discharged to a site other than the one coded on a claim.


Insufficient Documentation


While insufficient documentation is a distinct category used in the drill down of the CERT calculated improper payments, insufficient documentation spans across the medical necessity and incorrect coding categories. As outlined in the Complying with Medical Records Documentation Requirements Fact Sheet (November 2014)


Insufficient documentation errors identified by the CERT contractor included:


  • Incomplete progress notes (for example, unsigned, undated, insufficient detail);
  • No documentation of intent to order services and procedures (for example, incomplete or missing signed order or progress note describing intent for services to be provided)


Let’s take a look at the terminology of “insufficient documentation from a physician clinical perspective. Insufficient documentation relates to the physician not accurately and effectively capturing and reflecting his/her thought processes, clinical judgment, medical decision making, analytical skills and problem solving ability in services provided and/or ordered. Insufficient documentation is the main culprit for the majority of medical necessity denials. We will touch base upon the direct correlation between insufficient documentation and medical necessity denials in just a minute.


Insufficient spans the entire spectrum regardless of patient setting and type of service ordered and/or provided. A major concern and topic of discussion in the healthcare community is the Medicare two mid-night rule and the reasonable expectation of the patient requiring at least two mid-nights that are medically necessary for the workup and management of a patient. How does the physician capture this reasonable expectation of at least two mid-night hospitalization at the time a clinical decision is made in the record? This provides a nice Segway into the contentious topic of medical necessity.


Medical Necessity


Medical necessity and insufficient documentation unequivocally are interrelated, basically one and the same. While the concept of medical necessity can be construed to mean a financial tool for nonpayment by third party payers, used as a lethal weapon against hospitals and physicians, the physician can take full control and command through effective, concise, coherent and explicit documentation that clearly outlines the need for care and/or services. Outside parties judge the appropriateness of care provided and ordered strictly based upon the documentation available in the record. Effective and complete documentation does not require any more time, effort or energy, just the clinical facts of the case complemented by record of your clinical observations, thought processes, clinical suspicions, clinical rationale for diagnostic workup and therapeutic treatments, remembering to describe versus generalize and show versus tell as a fundamental basis for effective and complete documentation.


Effective and complete documentation can be considered in the following context, recognizing that documentation is the recording of information by individuals involved in providing clinical health services and that it is the most reliable indicator of the care that has been provided.


  • Every patient encounter should have a documented chief complaint
  • The History and Physical or outpatient encounter note should contain a clinically relevant History of Present Illness congruent with the nature of the patient’s presenting problem. There are eight elements to a HPI and far too often the intent of the HPI, that is a chronological account and description of the patient’s signs/symptoms and problems is not well documented when taking into account the nature of presenting problem
  • The History of Present Illness should remain focused upon the present illness versus the past illness, including clinically relevant history in the HPI that are directly related to the patient’s chief complaint and presenting signs and symptoms while including other pertinent history in the Past Family Social History part of the note.
  • The extent of the physical exam should incorporate the physician’s clinical judgment and take into account the patient’s expressed and recorded nature of presenting problem. The physical exam findings should correlate with the patient’s chief complaint and HPI; often times there is a distinct disconnect between what is recorded in the HPI and the physical findings, such as describing a patient with extreme respiratory distress while under the constitutional part of the physical exam recording that the patient appears to be in alert, oriented x 3 and in no respiratory distress
  • An assessment should contain definitive diagnoses expressed with clinical specificity of acute conditions (i.e., acute systolic CHF versus CHF), stability of chronic conditions (i.e., chronic stable acute systolic CHF, chronic kidney disease, stage IV)
  • Inclusion of comorbid clinical conditions that increase the complexity of management in the patient encounter documented in the assessment with appropriate clinical specificity
  • Documentation in the record should explicitly reflect the analytical assessment process involved in medical decision making
  • An assessment should contain documentation of any and all clinically relevant, pertinent differential diagnoses, diagnostic considerations and provisional diagnoses that will be entertained in the workup of presenting signs and symptoms, A typical example is chest pain and shortness of breath, diagnostic considerations, 1) NSTE MI in a patient with risk factors of family history of MI and early death, ) Pulmonary embolism in a patient with previous PE and sub therapeutic INR noncompliant, and 3) New diagnosis of acute CHF in a patient with risk factors of hypertension and coronary artery disease.
  • Clear and complete capture and reflection of the physician’s clinical judgment and complexity of the case as a matter of principle and establishment of medical necessity in the assessment and plan of care.

Closing Argument


Sufficient clinical documentation regardless of patient setting or encounter incorporates the accurate and complete recording and reflecting of the physician’s clinical judgment, thought processes and complexity of the care provided including the underlying challenges and consideration of diagnostic workup and therapeutic management. Clinical judgment can be defined as an encompassing assessment of the patient’s particular clinical scenario and the taking of action congruent with the assessment. Sufficient documentation does not correlate in the slightest with more documentation, just more effective documentation. In my next blog, I will be outlining and discussing additional strategies to consider in achieving best practices standards of clinical documentation in support of good patient, quality outcomes and smart effective care choices.