Knowledge Base Article

When a Medicare contractor, such as the Comprehensive Error Rate Testing (CERT) contractor, reviews your claims, they look for all the required documentation elements to support the medical necessity and performance of the services billed. And I mean ALL the elements. Indications and documentation requirements to support services are detailed in the Medicare manuals and coverage policies, both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Missing even one required element could result in a payment denial for your services.

One way Medicare assists providers in meeting documentation requirements is to publish examples of risk areas and their associated denial reasons in the Medicare Quarterly Compliance Newsletter. The January 2017 Newsletter is now available and there are several topics relevant to acute care hospitals.

Facet Joint Destruction (CPT 64635)

CPT 64635 is the destruction of lower or sacral spinal facet joint nerves using imaging guidance. Documentation requirements in general include:

• Documentation supporting the need for the procedure which includes any physician office notes, diagnostic findings, and other documentation that helps meet the indications for the procedure;
• A procedure note that adequately describes the service defined by the CPT/HCPCS code(s) billed; and
• Valid and legible physician signatures, including a signature log or attestation if needed.

In the examples given in the newsletter, the documentation failed to support that the patients received and failed conservative treatment as required by the LCD. Appropriate conservative treatments for this procedure may include local heat, traction, non-steroidal anti-inflammatory medications, and an anesthetic. There was also lack of a physician evaluation that included review of diagnostic or therapeutic procedures to diagnose facet joint pain and rule out other etiologies for the patient’s symptoms. In the end, these were determined to be insufficient documentation errors and the payments were recouped from the providers.

Radiation Therapy, CPT 77300 and 77301

For radiation therapy, the newsletter cited instances of insufficient documentation where the medical record was missing one or more of the following:

• Radiation oncologist's IMRT order/prescription;
• Radiation treatment plan including specifically planning notes with treatment fields, physics, and dosimetry calculations signed by the radiation oncologist and the medical physicist;
• Documentation to support review of the CT or MRI based images of the target and all critical structures;
• Weekly physics consult review with calculations for treatment delivery;
• A description of the service provided that matches the CPT code(s) billed; and
• Valid and legible physician signatures.

The missing documentation again led the CERT contractor to recoup the payment for the radiation services.

Stem Cell Transplant

An OIG review of claims from 2012 found 133 errors in appropriate patient setting for stem cell transplants that resulted in over $6 million in overpayments. Stem cell transplantation is not an inpatient only procedure and is often performed on an outpatient basis. The Geometric Mean Length of Stay (GMLOS) for the MS-DRGs primarily billed for stem cell transplants is 10-21 days. The errors identified by the OIG were for 1-2 day stays that could have appropriately been performed as outpatient. Although the criteria for inpatient admission has changed since 2012, hospitals and physicians still need to carefully evaluate if the patient meets the requirements to be an inpatient for stem cell transplant services, which would be an expectation that the patient will require care in the hospital beyond a second midnight.

So whether you are performing facet joint destruction, radiation therapy, stem cell transplants, or other services, when it comes to documentation for Medicare services, be sure you check all the boxes.