CMS Resources to Improve Provider Compliance

on Monday, 07 March 2011. All News Items

CMS has several claim review programs with the goal of reducing payment errors, such as Medicare Administrative Contractor (MAC) pre- and post-payment medical reviews, Comprehensive Error Rate Testing (CERT) program and the Recovery Audit Contractors (RACs) as well as the use of Medically Unlikely Edits (MUE) and National Correct Coding Initiative (NCCI) edits. In addition to these claim review programs, CMS periodically publishes education materials, such as educational tools, fact sheets and booklets designed to improve provider compliance. These education materials can be found on the Medicare Learning Network® MLN Products webpage (electronic versions available under MLN Publications). For example, the Medicare Claim Review Programs booklet describes the claim review programs mentioned above.

CMS recently released the second Medicare Quarterly Provider Compliance Newsletter, an MLN educational product that helps providers understand the major findings identified by Medicare Claims Processing Contractors, Recovery Au­ditors, Program Safeguard Contractors, Zone Program Integrity Contractors, and other governmental organizations, such as the Office of Inspector General. Topics of interest to hospitals in this edition include the following RAC findings:

  • Tracheostomy incorrect coding ,
  • Incorrect coding of injections / infusions and chemotherapy administration, and
  • Excisional debridement incorrect coding.

Another publication that would be of interest to hospitals is the Cardiac Pacemakers Fact Sheet which was developed in response to CERT findings. The most common dual-chamber pacemaker errors identified through the CERT review process were:

  1. No documentation to support the choice of a dual-chamber rather than a single-chamber pacemaker.
  2. Dual-chamber pacemaker implantation in patients with a clear contraindication, such as chronic atrial fibrillation.

Cahaba GBA, the Jurisdiction 10 MAC (Alabama, Georgia, and Tennessee) also recently released the findings of the November 2010 CERT data: Recent CERT Findings. The major CERT errors are still related to the lack of a physician’s order for laboratory and diagnostic services, failure to submit documentation to support diagnostic services, and the billing of a CBC with differential (CPT 85025) when the physician’s order only request a CBC (CPT 85027).

On Thursday, March 03, 2011, Cahaba GBA presented a webinar on CERT and CMS Signature Requirements. This presentation included details of recent CERT findings, problem documentation areas from Cahaba medical reviews (therapy, critical care, and ambulance), and information on signature requirements. Cahaba will be posting an encore of this webinar and the related questions and answers on their website ( ). MMP will add these documents to the Resource Library on our website ( ).

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