Knowledge Base Category -
Did You Know?
According to a National Cancer Institute, bladder cancer:
- Is the fourth most commonly diagnosed malignancy in men in the United States,
- Occurs about four times higher in men than in women,
- Is diagnosed almost twice as often in White individuals as in Black individuals of either sex; and
- The incidence of bladder cancer increases with age.
Blood in the urine is the most common presenting sign of bladder cancer, occurring in about 90% of cases. Other presenting symptoms include dysuria, urinary frequency or urgency, and less commonly, flank pain secondary to obstruction, and pain from pelvic invasion or bone metastasis.
Although hematuria is the most common presenting symptom, most people experiencing hematuria do not have bladder cancer.
Why it Matters?
There are risk factors related to being diagnosed with bladder cancer, most common being tobacco use, especially smoking cigarettes. Examples of additional risk factors includes:
- Having a family history of bladder, cancer,
- Having certain changes in the genes that are linked to bladder cancer,
- Being exposed to paints, dyes, metals, or petroleum products in the workplace,
- Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide,
- Taking Aristolochia fangchi, a Chinese herb,
- Drinking water from a well that has high levels of arsenic,
- Drinking water that has been treated with chlorine,
- Having a history of bladder infections, and
- Using urinary catheters for a long time.
What Can You Do?
First and foremost, if you smoke, quit! If you think you may be at risk for bladder cancer and/or are experiencing symptoms common for bladder cancer, discuss this with you physician. Time matters. The earlier bladder cancer is identified, the better chance a person has of surviving five years after diagnosis. The current five years relative survival rate is 77.1%.
What Can You Do?
- National Cancer Institute Cancer Stat Facts: Bladder Cancer: (https://seer.cancer.gov/statfacts/html/urinb.html)
- National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDQ®) Patient Version: (https://www.cancer.gov/types/bladder/patient/bladder-screening-pdq)
- National Cancer Institute Bladder and Other Urothelial Cancers Screening (PDF®) Health Profession Version: (https://www.cancer.gov/types/bladder/hp/bladder-screening-pdq )
Did You Know?
The Supplemental Medical Review Contractor’s (SMRC) activities are aimed at lowering Medicare Fee-for-Service (FFS) improper payment rates and increasing efficiencies of the medical review (MR) functions of Medicare. The Department of Health and Human Services Fiscal Year 2022 Justification of Estimates for Appropriations Committees (link) details goals for MR activities in the CMS Fiscal Year (FY) 2022, for example:
- For FY 2022, the request for funding for MR activities was $96.7 million, an increase by $50.5 million above the FY 2021 amount, and
- CMS expects the SMRC alone will review 792,800 claims in FY 2022, an increase from 80,197 claims in FY 2020.
Why it Matters?
Noridian Healthcare Solutions is the current SMRC (link) who performs nationwide reviews of Medicaid, Medicare Part A/B, and DMEPOS claims for compliance with coverage, coding, payment, and billing requirements.
As of April 7, 2022, the SMRC has twenty-five “Current Projects” listed on their website. Twelve of these have been added to their workload in CY 2022.
To date, in CY 2022, the SMRC has posted project results for the following five projects:
- 01-030: Botulinum Toxins – Medicare Part B Review: Error Rate 66%,
- 01-036: Hospice Portfolio: Error Rates 29% and 47%,
- 01-038: Facility Chronic Care Management (CCM): Error Rate 99%,
- 01-044: Therapy Reviews: Error Rate 31%, and
- 01-046: Inpatient Rehabilitation Facility (IRF) Stays Longer Length of Stay: Error Rate 54%.
What Can You Do?
First, be sure to respond to medical record requests from the SMRC as in general, common reasons for denial for a project will include the reason “no response to documentation request.” Also, take the time to read Noridian’s medical review findings for completed projects. Noridian’s review findings include a background about the review target, the reason the review was performed, common reasons for denial and any applicable references/resources (i.e., Federal Register, CMS Internet Only Manual (IOM), OIG reports, and National and Local Coverage Documents).
Did You Know?
The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.
Squamous cell carcinoma is most often found in the upper and middle part of the esophagus but can occur anywhere along the esophagus. Studies have shown that the risk of squamous cell carcinoma of the esophagus increases in people who smoke or are heavy drinkers.
Adenocarcinoma usually forms in the lower part of the esophagus near the stomach. This type of esophageal cancer is strongly linked to gastroesophageal reflux disease (GERD), especially when severe symptoms occur daily. Obesity in combination with GERD may further increase your risk for adenocarcinoma of the esophagus.
In the last 20 years the rates of adenocarcinoma of the esophagus have increased in the United States and is now more common than squamous cell carcinoma of the esophagus.
Esophageal Cancer Prevalence in the United States in 2021
- New Cases: 19,260
- Deaths: 15,530
Esophageal Cancer Risk Factors
- Tobacco Use,
- Heavy alcohol use,
- Barrett esophagus – Gastric reflux is the most common cause of Barrett esophagus,
- Men are about three times more likely than women to develop esophageal cancer,
- Older age,
- White men develop esophageal cancer at higher rates than Black men in all age groups
Signs and Symptoms of Esophageal Cancer
- Painful or difficult swallowing,
- Weight loss,
- Pain behind the breastbone,
- Hoarseness and cough
- Indigestion and heartburn
- A lump under the skin
Tests Used to Diagnose Esophageal Cancer
- Physical exam and health history,
- Chest x-ray,
Why this Matters?
In most cases, esophageal cancer is a treatable but rarely curable disease. The five-year survival rate is 19.9%.
Patients have a better chance of recovery when esophageal cancer is found early. Only 17.5% of patients are diagnosed with esophageal cancer at the local level. The five-year survival rate for this group of patients is 46.4%.
Signs and symptoms associated with esophageal cancer can also be present with other diseases. If you have any of the symptoms, discuss them with your doctor.
- PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 07/15/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389338]
- PDQ® Screening and Prevention Editorial Board. PDQ Esophageal Cancer Prevention. Bethesda, MD: National Cancer Institute. Updated 07/30/2021 Available at: (link). Accessed 04/04/2022. [PMID: 26389280]
- PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment (Adult). Bethesda, MD: National Cancer Institute. Updated 11/18/2021. Available at: (link). Accessed 04/04/2022. [PMID: 26389463]
Collaboration is a process of working together to complete a task or achieve a goal.
For the Clinical Documentation Integrity Specialist, the goal of ensuring a patient’s story can be accurately reflected in codes (ICD-10-CM/PCS, HCPCS, CPT), requires collaborating with a team that can include physicians, nursing, dietitians, physical therapists, case managers, social workers, and coding professionals.
For the Case Manager, to ensure a patient’s story supports medical necessity of the services being provided and the patient has an appropriate discharge plan in place, this process, in addition to the above professions, requires open communication with the patient and his or her “people.”
Physicians must also collaborate with a team. In fact, CMS recently updated their MLN Fact Sheet: Collaborative Patient Care is a Provider Partnership (link). This Fact Sheet opens with the following guidance:
“As a physician, supplier, or other health care provider, you may need to collaborate with other providers when providing care to your Medicare patients. For example, you may:
- Write orders
- Make referrals
- Request health care services or items for your patient
It’s important to understand Medicare coverage criteria and documentation requirements that apply for those services or items. This helps to ensure:
- Quality care for your patient
- Accurate and timely processing and payment of:
- Your claims, and
- The claims of other providers or suppliers who provide services or items for your patient
Note: This fact sheet is limited to information and documentation you need to support medical necessity when you partner with other providers. Other coverage and payment rules may also apply.”
Medicare Coverage Criteria and Documentation Requirements
Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states “No payment may be made under Part A or Part B for expenses incurred for items or services which…are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…”
At the national level, CMS publishes National Coverage Determinations (NCDs) and at the local level, Medicare Administrative Contractors (MACs) publish Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs). Coverage documents provide guidance for when a service is covered or not covered, and include indications for coverage, limitations of coverage, documentation requirements and billing and coding guidance.
It is important to become familiar with where to find these documents (Medicare Coverage Database (link) and identify any NCDs, LCDs, and/or LCAs that apply to services that you provide. For example, at the national level, there is a NCD for Implantable Automatic Defibrillators (20.4) (link). In addition to the NCD, several MACs have published a related Billing and Coding article.
Ensuring the Story is Correct
Understanding Medicare coverage criteria and documentation requirements is important. So much so, CMS utilizes Contractors (i.e., Recovery Auditors, Supplemental Medical Review Contractor, and MACs) to audit claims.
CMS notes in the MLN Fact Sheet, “Medicare audits frequently show that provider-submitted documentation doesn’t provide enough information to establish medical necessity. To ensure proper claims processing and payment, you must follow documentation requirements and meet Medicare coverage criteria.”
They also underscore the importance of documenting everything needed to meet Medicare payment requirements when collaborating with other Providers. For example, let us once again focus on implantable automatic defibrillators and the Shared Decision Making (SDM) encounter requirement. The SDM encounter is:
- A requirement for all patients receiving a defibrillator for primary prevention,
- Must occur between the patient and a Physician or Non-Physician Practitioner (i.e., Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist),
- An Evidenced-Based Decision Tool must be used to ensure topics like patient health goals and preferences are discussed,
- The encounter must occur prior to the initial implantation, and
- The encounter may occur at a separate visit.
Given the timing of when the SDM encounter should occur, it is likely that this would be done in the Physician’s office. Therefore, the physician would need to include in documentation provided to the hospital that an SDM encounter had occurred and what tool had been used.
CMS advises that a providers documentation needs to be thorough and accurate to support the medical necessity of services provided and should:
- Provide a thorough picture of what happened during the patient’s visit, and
- Tell why services or items you ordered or gave are medically necessary.
MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month’s focus is on bariatric surgery.
Did You Know?
There has been a National Coverage Determination (NCD) for bariatric surgery (100.1) since 1979. Originally titled Gastric Bypass Surgery for Obesity, the NCD is now titled Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity (link). This name change reflects the fact that treatment for obesity alone remains a non-covered indication for bariatric surgery.
Why Does This Matter?
Bariatric surgery has come under scrutiny by more than one review contractor, for example:
Supplemental Medical Review Contractor (SMRC): Strategic Health Solutions, the first SMRC contractor, completed a review of claims for bariatric service codes for dates of service from January 1, 2014, through December 31, 2014. In their review results, they cited a 35% error rate. The main reason for denials was due to insufficient documentation, for example: documentation did not include information supporting prior unsuccessful medical attempts at weight loss prior to surgical intervention.
Recovery Auditors (RACs): Complex medical reviews of inpatient and outpatient bariatric procedures has been an approved RAC Issue (link) since February 1, 2017.
Office of Inspector General (OIG): More recently, the Office of Inspector General published the report Hospitals Did Now Always Meet Differing Contractor Specifications for Bariatric Surgery (link). The OIG undertook this audit due to findings from a prior review of claims in 2015 and 2016 where they found claims did not fully meet a MAC’s eligibility specifications as well as the variance in eligibility specifications by different MACs. The audit included hospital inpatient claims for bariatric surgery performed from January 2017 through July 2018.
The OIG found thirty-two claims that met the NCD requirements, however the claims did not meet the MACs local specifications in their Local Coverage Determination (LCD) or Local Billing and Coding Article (LCA). Noridian had the most restrictive eligibility specifications in their LCA. The top specification not met was a lack of documentation indicating the beneficiary had participated in a weight management program. Novitas and First Coast had the least restrictive LCDs. The OIG estimated that “Medicare could have saved $47.8 million during our audit period if Medicare contractors had disallowed claims that did not meet Medicare national requirements or Medicare contractor specifications for bariatric surgery.”
OIG Audit Recommendations
Based on the audit findings, the OIG recommended that CMS:
- Determine if any of the MACs eligibility specifications in their LCDs or LCAs should be added to the NCD and if so, take steps to update the NCD,
- Work with the MACs to determine if any of the LCD or LCA eligibility specifications should be requirements rather than guidance, and
- If the NCD is updated, provide education to hospitals on the NCD requirements for bariatric surgery.
CMS did not agree with the OIGs recommendations. Two CMS responses were highlighted in the Report Brief:
- CMS will continue to monitor scientific evidence related to bariatric surgery and evaluate if an update to the NCD is needed, and
- “The Social Security Act does not mandate that LCDs be uniform across all jurisdictions and there are valid reasons that variations at the local Medicare contractor level is appropriate.”
What Can You Do?
If your hospital provides bariatric surgery services, I encourage you to read this OIG Report and perform a record review to ensure documentation supports the NCD requirements and when applicable your MAC LCDs and/or LCAs.
Did You Know?
45 is the new 50 for colorectal cancer screening.
Why It Matters?
The U.S. Preventive Services Task Force’s indicated in their May 18, 2021 Final Recommendation statement for colorectal cancer screening that (link):
- It is estimated that 10.5% of new colorectal cancer cases occur in persons younger than 50 years,
- Incidence of colorectal cancer (specifically adenocarcinoma) in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016,
- In 2016, 25.6% of eligible adults in the US had never been screened for colorectal cancer, and
- In 2018, 31.2% were not up to date with screening.
- Fecal occult blood test,
- Virtual colonoscopy, and
- DNA stool test.
- Colorectal cancer screening using MT-sDNA and blood-based biomarker tests for patients with Medicare Part B who meet these criteria:
- Aged 50-85 years,
- Asymptomatic, and
- At average risk of colorectal cancer risk.
- Screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas for patients with Medicare Part B who meet at least one criterion:
- Aged 50 or older at normal colorectal cancer risk (there’s no minimum age requirement for screening colonoscopies), or
- Are at high colorectal cancer risk.
What Can You Do?
There are five types of tests used to screen for colorectal cancer:
As a healthcare provider, be aware of Medicare’s colorectal screening coverage. According to the MLN Educational Tool Medicare Preventive Services (link), Medicare covers:
Also, Medicare has published a National Coverage Determination (NCD 210.3) Colorectal Cancer Screening Tests (link). The most current iteration of this NCD became effective on January 19, 2021, to include blood-based biomarker testing as an appropriate colorectal cancer screening test based on specific criteria.
My first screening colonoscopy was performed when I was 45 years old. During the procedure a pre-cancerous polyp was removed. As a healthcare consumer, I encourage everyone to talk with your doctor to discuss your risk for colorectal cancer and the need for screening tests.
Did You Know?
February is American Heart Month. Per NCD 210.11 (link), cardiovascular disease (CVD):
- Is the leading cause of mortality in the United States,
- Is comprised of hypertension, coronary artery disease (i.e., myocardial infarction and angina pectoris), heart failure and stroke, and
- Is the leading cause of hospitalizations.
Risk Factors for CVD includes:
- Being overweight,
- Physical inactivity,
- Cigarette smoking,
- High Blood Pressure (HTN),
- High blood cholesterol,
- Family history of myocardial infarction, and
- Older age
Why this Matters?
Annually, the CERT publishes a supplemental improper payment data report. Table D4, in the supplemental report (link), highlights the top 20 service types with the highest improper payments for Part A IPPS Hospitals. This table also details the percentage of error by each of the CERT’s major error categories:
- No documentation,
- Insufficient documentation,
- Medical necessity.
- Incorrect coding, and
In the 2021 supplemental data, nine of the top twenty service types with highest improper payments were DRGs in the major diagnostic category (MDC) 5 Diseases and Disorders of the Circulatory System. Insufficient documentation and medical necessity were the two most common type of errors cited for this group of service types.
The projected improper payment for the circulatory system service types is $714,632,739 representing 36% of the total projected improper payments for the top twenty service types.
What Can You Do?
Be proactive for your patients by becoming familiar with the cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease covered by Medicare and additional resources published in the February 10, 2022 edition of MLN Connects (link):
- Preventive Services webpage (link)
- Achieving Health Equity web-based training (link)
- CMS Office of Minority Health, Health Observances webpage (link)
- Million Hearts® (link): HHS initiative to prevent a million heart attacks and strokes
- Cardiovascular disease screenings coverage (link) & behavioral therapy (link): information for your patients
Become familiar with coverage determinations related to the top services. For example:
- For DRGs 226 and 227 (Cardiac Defibrillator Implant without cardiac catheterization with MCC and without MCC respectively), there is a National Coverage Determination (NCD 20.4) and Medicare Administrative Contractor (MAC) specific Local Coding and Billing Articles.
- Transcatheter Aortic Valve Replacement (TAVR) and TEER (Transcatheter Edge-to-Edge Repair) procedures fall within DRGs 266 and 267. Both procedures have a related NCD (TAVR NCD 20.32 and TEER NCD 20.33).
- Percutaneous Left Atrial Appendage Closure (LAAC) procedures fall within DRGs 273 and 274 and has a related NCD (20.34).
- For DRG 313 (Chest Pain), Palmetto GBA the Jurisdiction J and M MAC, has a Local Coverage Determination (LCD L34551) titled, One Day Stays for Chest Pain.
Finally, respond to requests for documentation in a timely manner, sending adequate documentation to support the medical necessity of the services provided.
Did You Know?
In October 2021, CMS published Change Request (CR) 12471 (link). There were two stated purposes for this CR noted in the Summary of Changes:
- • Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
- • Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason why laterality could not be determined
The effective date for this CR is April 1, 2022.
Why this Matters?
In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”
Effective for claims with dates of service on or after April 1, 2022, new Code Edit 20- will be triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.
You will find the complete list of 3,432 ICD-10-CM unspecified codes subject to this edit in table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule (link).
This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the providers responsibility to determine if documentation in the medical record support’s a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.
Mechanism to Bypass new MCE Edit 20-
The provider may enter a remark:
- • Either “UNABLE TO DET LAT 1” to indicate that they are unable to obtain additional information to specify laterality, or
- • “UNABLE TO DET LAT 2” to indicate the physician is clinically unable to determine laterality
However, “if there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”
“0 or 1 day” Length of Stay Claims
After reading this CR, my first thought was, how often are one of these codes being included on a claim. To find the answer, I turned to our sister company, RealTime Medicare Data (RTMD). Following are the numbers for Medicare Fee-for-Service paid claims data with dates of service from October 1, 2020, through August 31, 2021, available in RTMD’s footprint:
- • 57,951 claims included one of the unspecified codes in Table 6P.3a of the FY 2022 IPPS/LTCH Final Rule,
- • The paid claims total for this set of claims was $1,010,178,584.54, and
- • The top five states by claims volume included:
- o California: 5,926 claims - $135,738,052.81
- o Texas: 5,872 claims - $104,453,156.02
- o New York: 3,290 claims - $70,001,125.23
- o Pennsylvania: 3,192 claims - $48,281,839.67
- o Illinois: 2,750 claims - $41,821,442.35
What Can You Do?
This is not a large volume of claims in the world of Medicare Fee-for-Service Inpatient paid claims. However, just over $1 billion in paid claims is a significant amount of money. With a little over a month to prepare, you should make sure that CR 12471 and related MLN Matters article MM12471(link) are shared with key stakeholders at your facility (i.e., Billing, Coding, Clinical Documentation Integrity Specialists). You should also work with your IT department to anticipate the potential volume of claims that will be impacted by the new Code Edit 20-.
Fiscal Year 2021 Estimated Improper Payment Rates
In mid-November 2021, the Comprehensive Error Rate Testing (CERT) program published the Fiscal Year (FY) 2021 Annual CERT Report. A related Press Release, (link) noted that “CMS’ aggressive corrective actions led to an estimated $20.72 billion in reduction of Medicare Fee-for-Service (FFS) improper payments over seven years.”
While CMS cites an impressive reduction in improper payments over seven years, there was only a slight change from 2020 to 2021.
- Improper Payment Rate
- o FY 2020: 6.27%
- o FY 2021: 6.26%
- Improper Payment Amount
- o FY 2020: $25.74 billion
- o FY 2021: $25.03 billion
As I have noted in past articles, CMS noted in the Press Release that “while fraud and abuse may lead to improper payments, it is important to note that the vast majority of improper payments do not constitute fraud, and improper payment estimates are not fraud rate estimates.”
Fiscal Year 2021 Supplemental Improper Payment Data
The 2021 Supplemental Improper Payment Data Report (link) was published on December 12, 2021. This report highlights common causes of improper payments and includes tables allowing you to drill down into the review findings.
- From March 27, 2020, until August 10, 2020, CERT program activities were suspended,
- CMS reduced the claim sample size for FY 2021 (claims submitted July 1, 2019, through June 30, 2020), and
- Claims with dates of service within the COVID-19 PHE were reviewed in accordance with all applicable CMS waivers and flexibilities.
“0 or 1 day” Length of Stay Claims
Since implementation of the Two-Midnight Rule, the supplemental data report has included a table comparing improper payments rates for Part A hospital claims by length of stay (LOS). The improper payment rate for “0 or 1 Day” stay claims was highest in 2014 at 37.18% and in 2021 hit an all-time low of 16.8%. However, with the project improper payment rate being $1.5 billion, it is not surprising that Two-Midnight Stays are currently on the OIG Work Plan (link) and Livanta as the National Medicare Claim Review Contractor (link), is focusing their review efforts solely on Short Stay Reviews (SSRs) and Higher Weighted DRG (HWDRG) reviews.
Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS Table D4 of this report includes the top 20 DRG types with the highest improper payment rate. The table also details the percentage of error by each of the CERT’s major error categories:
- No documentation,
- Insufficient documentation,
- Medical Necessity,
- Incorrect Coding, and
Overall, 58.9% of the errors in this table were due to the error category medical necessity. The CERT places a claim into this category when the CERT contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. One hundred percent of the errors for the following four DRG Types was attributed to medical necessity:
- DRG 069: Transient Ischemia,
- DRGs 308, 309, 310: Cardiac Arrhythmia & Conduction Disorders,
- DRG 312: Syncope, and
- DRG 313: Chest Pain.
For the Septicemia DRGs 871 and 872, 37.2% of the errors was attributed to “no documentation.” Unfortunately, denied claims due to no documentation is also a frequent issue reported by the Medicare Administrative Contractors (MACs) and the Supplemental Medical Review Contractor (SMRC).
Moving forward, here are ideas and resources to help in your efforts to prevent claims errors:
- Visit the CERT Provider Website (link) to find information about the CERT, how to submit records, sample request letters and much more.
- Become familiar with National and Local Coverage Determinations and Local Coverage Articles that detail indications and limitations of specific services. For example, DRGs 469 and 470 (Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity) had the highest projected improper payment in Table D4 at $724,055,597. The CERT attributed 19.5% of the error to insufficient documentation and 80.3% to medical necessity. CMS has published an MLN Booklet titled Major Joint Replacement (Hip or Knee) (link) that provides guidance on what to document to avoid denied claims.
- Become familiar with and utilize your hospital’s Program for Evaluating Payment Patterns Electronic Report (PEPPER).
- And finally, take the time to review the CERT’s Supplemental Improper Payment Data report annually.
A related article in this week’s newsletter (link), provides detail from the 2021 Comprehensive Error Rate Testing (CERT) program annual report and annual supplement data to the report. This article provides key facts about the CERT.
About the CERT
- The objective of the CERT program is to monitor and report the accuracy of claims payment in the Medicare Fee-for-Service program.
- CMS uses the CERT error rate to evaluate the performance of the Medicare Administrative Contractors (MACs).
- There are two CERT contractors:
- The CERT Review Contractor (CERT RC), and
- CERT Statistical Contractor (CERT SC).
- The CERT claim selection includes a stratified random sample of approximately 50,000 claims that are chosen by claim type (Part A, Part B and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), and includes paid and denied claims by the MAC.
- The CERT process is a federally mandated program and not responding to documentation requests will result in a denial of all services billed on the claim.
- CERT request letters are mailed to the correspondence address listed in the Provider Enrollment, Change and Ownership System (PECOS).
- You can submit requested documentation to the CERT via postal mail, fax, Electronic Submissions of Medical Documentation (esMD), via CD or via email attachment(s).
- For short (less than 24 – 48 hours stay) inpatient hospital stay, a discharge summary is not required when a beneficiary is seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary.
- The billing provider is responsible for obtaining medical records from the third-party to substantiate the claim that was billed.
- The CERT makes every effort to obtain the request documentation. Providers have 45 days to respond to the first letter requesting documentation. When the CERT does not receive the requested documentation by the 75th day, a claim is counted as a non-response error and is subject to overpayment recovery by the MAC.
- Claims reviews by the CERT includes program checks for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and provision in the CMS instructional manuals.
- Denied claims as well as overpayments and underpayments are all considered to be an improper payment by the CERT program.
- Improper payments are attributed to one of five major error categories (no documentation, insufficient documentation, medical necessity, incorrect coding, or other).
- The improper payment rate is not a “fraud rate,” but a measurement of payments that did not meet Medicare requirements.
- Providers that wish to appeal a CERT contractor’s determination can follow the normal redetermination process to appeal all CERT denials.
- The CERT A/B MAC Outreach & Education Task Force has a goal to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force webpage (link) includes education resources for providers.
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