Knowledge Base Article

It is still quite warm here in the deep South so it seems crazy to think that Christmas is only a little over two months away. It is a joyous time of year, but also an extremely busy and stressful time. I should be making my list now of all I have to do in order to be ready. I wonder if Santa Claus, in keeping with the words of a famous Christmas song, is “making a list and checking it twice” so he can determine who is naughty and who is nice? It appears the Medicare Comprehensive Error Rate Testing (CERT) program contractor also has some naughty and nice lists.

The CERT auditors are somewhat different from most other Medicare reviewers. They do not target at-risk issues or use data analytics to select specific topics. Instead they perform random audits of all claims to determine if the Medicare Administrative Contractors (MACs) are paying claims correctly. Their reviews produce overall error rates for the various MACs. These random reviews result in the CERT having lower error rates than those of targeted reviews, but also allow a broader brush of the pen. Using this random approach allows the CERT to identify new and unexpected issues that often then become an “at-risk” issue for the MACs to review further in their targeted reviews.

Medicare publishes a Quarterly Provider Compliance Newsletter that provides education on how to address common billing errors and other claim review findings. The October 2016 edition provides feedback from some CERT findings related to several different types of procedures. One other good thing about CERT reviewers is that they make multiple attempts to obtain the appropriate documentation unlike other reviewers who just go with what is submitted the first time. But once documentation requests attempts are exhausted, it seems apparent that the CERT reviewer checks off a list of what documentation elements must be included to justify payment for the services.

The procedures reviewed by CERT and addressed in the newsletter that are most likely to affect hospitals are venous transluminal balloon angioplasty procedures (HCPCS code 35476) and endovenous ablation therapy (EVAT) of incompetent veins (HCPCS code 36475). Denials for both of these procedures were mainly due to:

• No documentation to support the medical need for the procedure
• No procedure or operative note
• No documentation of diagnostic studies required for coverage, and
• No physician’s signature on a procedure note, diagnostic report or progress note

Specific examples given in the newsletter provide further insight.

• A letter was sent to the CERT program, but the documentation in the medical record was still incomplete documentation.

“Note that physician attestations by themselves do NOT provide sufficient documentation of medical necessity, even if signed by the ordering physician. For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary’s medical documentation and confirm that Medicare coverage criteria have been met.”

• There must be a signed order or signed documentation of intent to order the service.

There is nothing more to say - you have to have an order or documented intent and it must be signed.

• Documentation in the medical record (progress notes, operative notes, diagnostic studies, etc.) must be signed by the performing physician.

Signatures cannot be added at a later time (especially after a copy of the unsigned documentation has been submitted to CERT). In some cases, it is appropriate to provide an attestation verifying the authorship of unsigned or illegibly signed documentation. For more information on Medicare signature requirements, see Complying with Medicare Signature Requirements Fact Sheet and MLN Matters Article SE1419 - Medicare Signature Requirements Educational Resources

• There must be documentation of the reason/need to perform the procedure.

Hopefully procedures would not be performed without a reason to do so – make sure the H&P includes the medical justification for the need for the procedure. If Medicare has specific criteria for the procedure (such as a National or Local Coverage Determination), there must be documentation fulfilling those requirements – for example, documentation supporting failed conservative treatment before the procedure if required.

• There must be a procedure or operative note supporting that the service was performed.

This one seems obvious, but a physician’s progress note post-procedure documenting completion of a successful procedure does not fulfill this requirement.

I recommend reading through this quarter’s Compliance Newsletter. The examples are entertaining (though likely not to those whose claims were denied) and you will definitely learn about the requirements for these procedures and procedures in general. This may allow you to proactively review the documentation in your own records and you can use the examples in the newsletter to educate staff and physicians if a need is identified.

You may even decide to make a list and check it twice…