Knowledge Base Article

Everyone knows that in medical record documentation you have to be sure to “say what you did.” But don’t forget that it also has to be authenticated, dated, legible, timely, and include documentation to not only support the service provided, but the clinical indications for why it was provided. Sort of an extended version of “who, what, when, where, and why…”

Our focus this month is the medical review of claims containing CPT code 33249 (Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber). There has been a lot of concern about appropriate billing of AICDs; in fact over the last few years the Department of Justice has investigated these claims to determine if they meet the requirements of the National Coverage Determination (NCD). All of this attention on AICDs is due to high-dollar reimbursement and a long and complex NCD. The Medicare Quarterly Compliance Newsletter for October 2014 discusses the findings of a special study of CPT 33249 by the Comprehensive Error Rate Testing (CERT) program. The CERT review found that many improper payments were made due to insufficient documentation and medical necessity errors.

I will not address all of the requirements for AICDs in this article, but will concentrate on the deficiencies sighted in the Compliance newsletter. For complete information on AICD coverage, please see the NCD for Implantable Automatic Defibrillators (20.4).

The CERT study found that approximately 85 percent of the improper payments were due to insufficient documentation, meaning the required information was missing from the medical record or was inadequate to support payment. Services that were not medically necessary, based on Medicare coverage policies, accounted for approximately 12% of the improper payments.

Signature Issues:

• The procedure note was not signed by the physician.
• There was not a signature log or attestation for cases in which the physician’s signature was illegible.
• There was a lack of policies for electronic signature process in electronic health records, when applicable.
• Clinical records supporting the patient’s history of heart disease were not authenticated.
• A second copy of a previously unsigned post-operative history and physical examination note was submitted to which a signature had been added without a signature date. Providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead should make use of the signature authentication process.

Date of Service:

• There was a lack of records for the specified date of service.
• An operative report showed that the patient had an AICD implanted; however, the date on the report did not match the billed date of service. Medicare payment rules do not allow reviewers to accept documents with dates that are significantly different from the billed date of service.

Clinical Indication:

• Documentation did not support the clinical indication for the procedure.
• Clinical documentation did not support a previous Myocardial Infarction (MI). MIs must be documented and defined according to the consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction

Clinical Trial:

• There was a lack of records to support the patient was enrolled in a clinical trial/study. Patients receiving defibrillator implantation for primary prevention must be enrolled in either:
• A Food and Drug Administration (FDA) approved category B investigational Device Exemption (IDE) clinical trial;
• A trial under the CMS Clinical Trial Policy; or
• A qualifying data collection system including approved clinical trials and registries.
• Documentation of enrollment in a clinical trial/study is required to support the use of the Q0 (Q zero) modifier.

Lack of Medical Necessity:

• For all AICDs, the beneficiary must not have irreversible brain damage from preexisting cerebral disease.
• For primary prevention of sudden cardiac death, criteria include that the beneficiary must not have:
• Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm;
• Had a Cardiopulmonary Artery Bypass Graft (CABG) surgery or Percutaneous Transluminal Coronary Angioplasty (PTCA) within the past 3 months;
• Had an acute Myocardial Infarction (MI) within the past 40 days;
• Clinical symptoms or findings that would make them a candidate for coronary revascularization; or
• Any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than 1 year.

Amendments, Corrections and Delayed Entries:

• Medical record amendments, corrections and delayed entries must comply with the widely accepted Recordkeeping Principles described in the Medicare Program Integrity Manual, Chapter 3 (Section 3.3.2.5 (Amendments, Corrections and Delayed Entries in Medical Documentation), Section B (Recordkeeping Principles) to be considered for review determinations.
• Medicare Reviewers do not consider any entries that do not comply with the principles listed in Section B, even if such exclusion would lead to a claim denial.
• For example, undated or unsigned entries handwritten in the margin of a document are excluded from consideration.

So be sure your medical records contain sufficient information to support your Medicare billing. But be especially mindful of those AICD records – that’s a lot of money!!

One other note about Medicare Administrative Contractor (MAC) medical reviews – CMS now requires that MACs post their review topics to their public websites (see Transmittal 527). This requirement was effective September 5, 2014. You will notice on this month’s MAC Review table that First Coast (Jurisdiction N MAC) has added numerous current review topics. These may have been noted on their website previously, but this is the first time I have been able to locate this information.