--- title: Documentation Critical to CMS Claims, Patient Care and Medical Reviews description: Complying with CMS documentation requirements remains critical to SNF/senior living success. With claims errors, documentation is 2 of the top 5 reasons. image: https://info.primecaretech.com/hubfs/Email%20Banners/Top-5-cms-claims-errors-primeclaims-snf-revenue-cycle-banner.png --- [![PCT PCD Email Signature (524 x 102 px) (300 x 100 px) (1)](https://www.primecareholdings.com/hs-fs/hubfs/PCT%20%20PCD%20Email%20Signature%20(524%20x%20102%20px)%20(300%20x%20100%20px)%20(1).png?width=300&height=100&name=PCT%20%20PCD%20Email%20Signature%20(524%20x%20102%20px)%20(300%20x%20100%20px)%20(1).png) ](https://www.primecareholdings.com/prv) [![Request A Demo](https://no-cache.hubspot.com/cta/default/79917/f5e6168c-e0a4-45aa-912f-32a380cc04e5.png)](https://cta-redirect.hubspot.com/cta/redirect/79917/f5e6168c-e0a4-45aa-912f-32a380cc04e5) ###### 2 min read # [Documentation Critical to CMS Claims, Patient Care and Medical Reviews](https://www.primecareholdings.com/news/documentation-critical-to-cms-claims-patient-care-and-medical-reviews) By [Prime Care Tech Marketing](https://www.primecareholdings.com/news/author/prime-care-tech-marketing) on Thu, Jun 17, 2021 @ 04:10 PM ###### Topics: [revenue cycle management](https://www.primecareholdings.com/news/topic/revenue-cycle-management) [SNF](https://www.primecareholdings.com/news/topic/snf) [CMS](https://www.primecareholdings.com/news/topic/cms) [primeCLAIMS](https://www.primecareholdings.com/news/topic/primeclaims) [denial management](https://www.primecareholdings.com/news/topic/denial-management) ![Documentation Critical to CMS Claims, Patient Care and Medical Reviews](https://info.primecaretech.com/hubfs/Email%20Banners/Top-5-cms-claims-errors-primeclaims-snf-revenue-cycle-banner.png) As outlined by the Centers for Medicare and Medicaid Services (CMS), [Complying with Medical Record Documentation Requirements](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909160) remains critical to senior care success. Proper documentation: - Helps patients get reasonable and necessary items/services - Facilitates proper claim payment - Supports favorable medical review decisions Specific to claims reimbursement, CMS identified the top five reasons for errors. Note, two are related to documentation.  [![Top-5-cms-claims-errors-primeclaims-snf-revenue-cycle](https://info.primecaretech.com/hubfs/Infographics/Top-5-cms-claims-errors-primeclaims-snf-revenue-cycle.png)](https://www.gotostage.com/channel/1814324d6d794311a3567f26a505eda6/recording/946d887bd7304cd8bf5e4f799f63fb9f/watch) So, what does insufficient documentation mean? - It does NOT mean documentation doesn’t exist. - It means something was incomplete or missing at claim submission. And, what are the consequences of improper documentation? Improper documentation disrupts the [revenue cycle](https://www.primecareholdings.com/snf-revenue-cycle-management-primeclaims-ltc), which results in loss of financial revenue. CMS [claim denials](https://www.primecareholdings.com/snf-revenue-cycle-management-primeclaims-ltc) also cost your staff time, requiring them to: - Complete forms - Submit additional documentation - Send a letter explaining why the claim should be paid - Resubmit claim Secondarily, if your order for item/service is illegible, your patient care suffers. What are some tips for improved documentation? - Send ALL associated documentation supporting the item/service billed - Some information may come from a prior claim or test - If you're not sure if certain documentation is required, send it anyway - Send the documentation by the deadline indicated in the request - Review documentation to make sure it: - Answers who, what, when, why, and how - Verifies item/service was performed - Verifies medical necessity Where can I get more information regarding CMS claims errors, including documentation? - [Complying with Medical Record Documentation Requirements](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909160) - [Complying with Medicare Signature Requirements](https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1246723) Lastly, senior care and skilled nursing facilities (SNFs) can greatly simplify claims revenue management by employing a system customized for this industry, and supported by seasoned claims professionals. [Get in touch](https://www.primecareholdings.com/demo-request-prime-care-technologies) if we can help. 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