Medication Administration

Insufficient documentation means something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for medication administration. 

Incomplete Physician Order:  The physician who is treating the beneficiary must sign and date the medication order. The complete medication order must include the following:

• • Medication name
  • Dosage
  • Route of administration
  • Frequency of administration

Missing Medication Administration Record (MAR):  The MAR is the report that serves as a legal record of the drugs ordered and administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical chart. The health care professional signs off on the record at the time that the drug is administered.

Missing Medical Necessity Documentation: The documentation must support the medical necessity for ordering the medications and must be present in the patient’s medical record.

Related Content

• • CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50 (Drugs and Biologicals)
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 17 (Drugs and Biologicals)
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2 (Reasonable and Necessary Criteria)

Reviewed 11/14/2024