Quarterly CERT Error Findings Report WPS GHA Part B J5 MAC ~ Iowa, Kansas, Missouri and Nebraska ~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed January 1, 2018, through March 31, 2018, for J5 Part B providers. The findings below are reported based on the type of error assessed by the CERT contractor (e.g., insufficient documentation, incorrect coding, etc.). Insufficient Documentation - 65% of total errors Missing the physician s order for or documentation to support the intent to order prothrombin time and the treating physician s clinical documentation to support the medical necessity of the lab study. CERT received a screen shot of documentation for the Date of Service (DOS) indicating the beneficiary was seen for INR lab test and includes result of study, dose of warfarin to be taken and is electronically signed by an RN. Per the SSA 1833(e), 42 CFR 424.5(a) (6) (Sufficient Information), 42 CFR 410.32(a)(ordering diagnostic tests), the Internet Only Manual (IOM) Publication 100-02, Chapter 15, 80.6.1 (Requirements for Ordering and Following Orders for Diagnostic Tests) and the IOM Publication 100-08, Chapter 3, 3.6.2.2 (Reasonable and Necessary Criteria). The submitted documentation is insufficient to support the billed service per Medicare requirements. Missing the medical observation record for the beneficiary which contains dated and timed physician s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. CERT received an authenticated History and Physical (H&P) missing an order for billed observation care and a discharge summary. Per the SSA 1833(e), 42 CFR 424.5 (a)(6), CPT 2017, the IOM Publication 100-04, Chapter 12, 30.6.1 (Selection of Level of Evaluation and Management Service), and 30.6.8 (Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services). The documentation submitted is insufficient to support this service per Medicare guidelines. Missing the treating physician's order or clinical documentation to support the plan or intent to order the specific test for date of service and the treating physician's clinical documentation to support medical necessity. CERT received an authenticated renal ultrasound report. Per the SSA 1833(e), 42 CFR 424.5(a)(6)(sufficient information), 42 CFR 410.32(a)(Ordering diagnostic tests), the IOM Publication 100-02, Chapter 15, 80.6 (Requirements for Ordering and Following Orders for Diagnostic Tests), and the IOM Publication 100-03, Chapter 1, 220.5 (Ultrasound Diagnostic Procedures), the submitted documentation is insufficient to support this claim per Medicare guidelines. Missing an attestation for the billed CRNA anesthesia services. CERT received an anesthesia record signed illegibly by the billing CRNA; the post evaluation is included within this record and the illegibly signed pre-anesthesia record. Per the SSA 1833(e), 42 CFR 424.5(a)(6) (Sufficient information), the IOM Publication 100-04, Chapter 1, Section 110 (Provider Retention of Health Insurance Records), and the IOM Publication 100-08, Chapter 3, Section 3.3.2.4 (Signature Requirements). The submitted documentation is insufficient to support Medicare requirements. Missing a copy of the signed and dated Physician Certification Statement (PCS) for non-emergent Basic Life Support (BLS) transport, or documentation of attempts to obtain certification for the billed date of service. CERT received an ambulance transport record with mileage and signatures and the Page 1 of 5
AOB. Per the SSA 1833 (e) (Insufficient Documentation), 42 CFR 410.40(d)(3)(iii) - Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis, 42 CFR 424.36(b)(6) (Signature Requirements Ambulance Claims), The CERT Manual Version 23.0 section 4.6.3 (Ambulance Services), the IOM Publication 100-04, Chapter 15 (Ambulance), and the IOM Publication 100-02, Chapter 10, 10.2 (Necessity and Reasonableness). Missing a copy of the fundus photos to support fundus photography with interpretation and report and the physician s signature attestation to the unsigned fundus photo report. CERT received a progress note with a typed signature that does not indicate it is an electronic signature and an unsigned fundus photo report. Per the SSA 1833(e), 42 CFR 424.5(a) (6) (Sufficient Information), the IOM Publication 100-08, Chapter 3, 3.3.2.4 (Signature Requirements), the IOM Publication 100-02, Chapter 15, 80.6.1 (Requirements for Ordering and Following Orders for Diagnostic Tests), the IOM Publication 100-04, Chapter 1, 110.1 (Categories of Health Insurance Records to Be Retained), the submitted documentation is insufficient to support the billed service per Medicare requirements. Missing the physical therapy initial evaluation relevant to the billed DOS; the treating physician's signed and dated certification of the plan of care for therapy services billed. CERT received an authenticated physical therapy progress note documenting a beneficiary with chronic low back and mid back/neck pain presenting for the 7th treatment visit with recommendation for aquatic therapy to be initiated and documents 48 minutes of aquatic therapy and 15 minutes of heat/e-stim for a total time of 63 minutes. The note further documents a plan for aquatic therapy 1x week and continue land therapy 1x week for next 6 weeks to include long term goals. Per the SSA 1833(e), the IOM Publication 100-02, Chapter 15, 220.3 (Documentation Requirements for Therapy Services), 220.1.3 (Certification / Recertification of need for treatment and therapy plans of care), and 230.5.D (therapy provided incident to), the submitted documentation is insufficient to support this claim per Medicare guidelines. Service Incorrectly Coded 24% of total errors The documentation supports a down code from 99233 to 99232 with a problem focused history, detailed exam, and medical decision making of moderate complexity based on the documentation submitted. CERT received an authenticated visit note that does not meet the required 2 of 3 key components (detailed history, detailed exam, medical decision making of high complexity) for the level of Evaluation and Management (E/M) billed. Per the 1995-97 E/M guidelines, the IOM Publication 100-04, Chapter 12, 30.6.1 (Selection of Level of E&M Service), 30.6.9.2 (Subsequent Hospital Visit), and CPT 2017. The documentation supports an up code from 99222 to 99223 with a comprehensive history, a comprehensive exam, and medical decision making of high complexity based on the documentation submitted. CERT received an authenticated hospital visit note that exceeds the required 3 of 3 key components (comprehensive history, comprehensive exam, medical decision making of moderate complexity) for the level of E/M billed. Per the 1995 E/M guidelines, CPT 2017 and the IOM Publication 100-04, Chapter 12, 30.6.1 (Selection of Level of Evaluation and Management Service). The documentation submitted supports a code change from 99212 to 99213, modifier 25, with an expanded, problem focused history, an expanded, problem focused exam and medical decision making of low complexity. CERT received an authenticated progress note that exceeds the required 2 of 3 key elements (problem focused history, problem focused exam and straight forward medical decision making) for the billed E/M. Per the CPT 2017, 1995 E/M guidelines, and the IOM Publication 100-04, Chapter 12, 30.6.1 (Selection of Level of Evaluation and Management Service). Based on an IRR Panel review decision, the Billed 85025, Comprehensive Blood Count (CBC) with differential is changed to 85027, CBC without differential. CERT received the lab results, the requisition, an order for a CBC, Comprehensive Metabolic Panel (CMP) and Thyroid Stimulating Hormone assay (TSH), a visit note that documents nursing staff asked for the patient to be seen for Page 2 of 5
bronchitis and weakness and documenting the intent for CMP, CBC and TSH. Per the SSA 1833(e)(insufficient documentation), the IOM Publication 100-02, Chapter 15, 80 (Requirements for Diagnostic Laboratory, and Other Diagnostic Tests), 80.1 (Clinical Laboratory Services) and 80.6 (Requirements for Ordering and Following Orders for Diagnostic Test). The physician order was for a CBC, not a CBC with differential. Other Errors 7% of total errors Technical billing error: there is no referring or ordering NPI identified on the claim and the attending physician of record is the billing provider. CERT received an inpatient psychiatric evaluation performed via telehealth, and the consent for telepsychiatry. Per the IOM Publication 100-04, Chapter 26, 10.4- Item 17, "All claims for Medicare covered services and items that are the result of a physician's order or referral shall include the ordering/referring physician's name. The following services/situations require the submission of the referring/ordering provider information: Consultative services". Based on the SSA 1833(e), CPT 2016, 42 CFR 424.5(a)(6)(sufficient information), the IOM Publication 100-04, Chapter 12, 190.3.1 and 190.3.2 (Telehealth Consultation Services, Emergency Department or Initial Inpatient), the SSA 1834(m)(Telehealth Services), 42 CFR 410.78 (Telehealth Services), and the IOM Publication 100-04, Chapter 26, 10.4 (Provider of Service or Supplier Information- Item 17). It is noted that there was no referral or request for consultation or follow up documentation supporting the findings of the consultation were provided to the referring physician. Technical billing error: missing documentation to support a face-to-face follow up consultation encounter provided via a telecommunication system, and the attending physician s or other qualified individual s order or referral for telehealth consultation follow-up for the billed DOS. CERT received a visit note that does not document a follow up face to face consultation furnished by a telecommunications system. It is noted that the billing physician is listed as the attending physician on both the inpatient claim and the visit note for the billed DOS. This claim was submitted without modifier GT or GQ. The Referring physician is listed on the claim as the same physician performing the service. Per the SSA 1833(e), 42 CFR 410.78 (Telehealth Services), 42 CFR 141.65 (Payment for Telehealth Services), the IOM Publication 100-04, Chapter 12, 190.3.1 (Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits), 190.3.3 (Follow-Up Inpatient Telehealth Consultations Defined), and 190.6 (Payment Methodology for Physician/Practitioner at Distant Site) Medically Unnecessary Service or Treatment 2% of total errors The billed lab was not reasonable and necessary so therefore the venipuncture is not reasonable and necessary. CERT received an unsigned order for the billed valproic acid test, the lab test, a note stating: Dr did not order lab for this patient, a signature attestation missing credentials of the provider, and is illegibly signed by an APRN without legible identifier, a Medication Administration Record (MAR) which is illegibly signed by the NP, a trip log which supports 6.8 miles per beneficiary. Per the SSA 1862(a)(1)(A) and the IOM Publication 100-02, Chapter 16, 180 (Services Related to and Required as a Result of Services Which are Not Covered Under Medicare), since the lab services are missing an order and documentation of medical necessity, the venipuncture is not reasonable and necessary. Page 3 of 5
Unbundling 1% of total errors The billed service is for infusion of normal saline, 250 cubic centimeters (cc) for 1 Unit of Service (UOS). The documentation supports the normal saline was used to reconstitute the Infliximab and to facilitate the administration of the drug with no separate payment allowed for this. CERT received: a progress note that documents a beneficiary on Infliximab and methotrexate with psoriatic arthritis and a copy of the Infusion record. Per the SSA 1833(e) (Insufficient Documentation), the IOM Publication 100-04, Chapter 12, 30.6.5 (Payment Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions), 30.6.5 C (Therapeutic, Prophylactic, and diagnostic injections and infusions), 30.6.5 D (Chemotherapy Administration), A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable. Payment for the normal saline solution is included in the payment for the drug. No Response - 1% of total errors No Medical records were received Based on CERT error findings for this quarter, below are educational resources that can assist in avoiding these issues in your practice. CMS Resources Necessity and Reasonableness CMS IOM, Publication 100-02, Chapter 10, Section 10.2 Requirements for Ordering and Following Orders for Diagnostic X-ray, Diagnostic Laboratory and Other Diagnostic Tests CMS IOM, Publication 100-02, Chapter 15, Section 80. Definitions CMS IOM, Publication 100-02, Chapter 15, Section 80.6.1 Certification/Recertification of the Need for Treatment and Therapy Plans of Care CMS IOM, Publication 100-02, Chapter 15, Section 220.1.3 Documentation Requirements for Therapy Services CMS IOM, Publication 100-02, Chapter 15, Section 220.3 Therapy Provided Incident to CMS IOM, Publication 100-02, Chapter 15, Section 230.5.D Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare CMS IOM, Publication 100-02, Chapter 16, Section 180 National Coverage Determination (NCD) 190.15 Blood Counts CMS IOM, Publication 100-03, Chapter 1, Section 190.15 National Coverage Determination (NCD) 190.22 Thyroid Testing CMS IOM, Publication 100-03, Chapter 1, Section 190.22 National Coverage Determination (NCD) 220.5 Ultrasound Diagnostic Procedures CMS IOM, Publication 100-03, Chapter 1, Section 220.5 Provider Retention of Health Insurance Records CMS IOM, Publication 100-04, Chapter 1, Section 110. Selection of Level of Evaluation and Management CMS IOM, Publication 100-04, Chapter 12, Section 30.6.1 Page 4 of 5
Payment Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions CMS IOM, Publication 100-04, Chapter 12, Section 30.6.5 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions CMS IOM, Publication 100-04, Chapter 12, Section 30.6.5 C. Chemotherapy Administration - CMS IOM, Publication 100-04, Chapter 12, Section 30.6.5 D. Payment for Hospital Observation Services and Observation or Inpatient Care Services - CMS IOM, Publication 100-04, Chapter 12, Section30.6.8 Payment for Initial Hospital Care Services and Observation or Inpatient Care Services - CMS IOM, Publication 100-04, Chapter 12, Section 30.6.9.1 Subsequent Hospital Visit - CMS IOM, Publication 100-04, Chapter 12, Section 30.6.9.2 Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management Visits- CMS IOM, Publication 100-04, Chapter 12, Section 190.3.1 Follow-Up Inpatient Telehealth Consultations Defined- CMS IOM, Publication 100-04, Chapter 12, Section 190.3.3 Payment Methodology for Physician/Practitioner at Distant Site- CMS IOM, Publication 100-04, Chapter 12, Section 190.6 Ambulance Services CMS IOM, Publication 100-04, Chapter 15. Organ or Disease Oriented Panels CMS IOM, Publication 100-04, Chapter 16, Section 90.2 Provider of Service or Supplier Information CMS IOM Publication 100-04, Chapter 26, Section 10.4 Provider Signature Requirements CMS IOM, Publication 100-08, Chapter 3, Section 3.3.2.4 Reasonable and Necessary Criteria -- CMS IOM, Publication 100-08, Chapter 3, Section 3.6.2.2 WPS GHA Resources Additional WPS GHA Portal Resources: CERT Manual Version 23.0 Section 4.6.3 (Ambulance Services) CERT Error Analysis 1995-1997 E/M Guidelines Note: Review results are based on the documentation submitted and Medicare regulations in place at the time services were rendered. Medicare providers are responsible for compliance with all current applicable Medicare coverage, coding and billing regulations upon claim submission. Page 5 of 5