WPS Medicare Part B - Quarterly CERT Error Findings Report ~ MICHIGAN ~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed July 2014 through September 2014 for Michigan 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 - 78% of total errors Provider billed for initial hospital encounter and subsequent hospital encounters and submitted attestation to signatures and copy of illegible notes. Unable to read large sections of the notes, therefore unable to verify billed encounter codes. Claim billed for office evaluation and management service (CPT 99215). Unable to read provider's handwriting on note submitted. Billing for home visit, evaluation and management services provided in a private residence (CPT 99349-25). Missing documentation to support the medical necessity of the home visit made in lieu of an office or outpatient visit. Received the home visit note but there is no documentation supporting this patient is homebound. Billed 99220 (initial observation care, per day evaluation and management (E/M service). Submitted documentation is missing the billing provider's clinical documentation to support face to face evaluation and involvement in the E/M service billed. Documentation initially submitted included progress note from different provider; discharge summary from billing provider; emergency room and observation care documents. Claim billed for ESRD monthly visit with 2-3 face to face visit by a physician or other qualified health care professional per month (CPT 90961). Submitted documentation is missing the face to face evaluations to support code as billed. Submitted documentation included only one face to face visit signed by NP in same group practice as billing physician. Billed psychiatric diagnostic evaluation (CPT 90791). Missing the billing provider signed and dated progress note to support billed service. Submitted documentation includes a very comprehensive report for another date, with multiple Evaluation Dates, and cumulative progress notes that document what intervention was done on each date. Requested additional documentation from billing provider and received attestation statement only Billed 00670-QK - anesthesia for extensive spine and spinal cord procedures. Submitted documentation includes illegible signed anesthesia record, operative reports, surgical nursing record, and illegible signed pre-evaluation. Requested additional documentation from billing provider and received duplicate documentation. Billed CPT 71270 CAT scan, thorax w/o & w/ dye, Modifiers 26 (professional component) and 59 (Distinct Procedural Service). Missing documentation of the plan or intent to order the CT Page 1 of 5
scan and documentation that supports medical necessity and the need for the CT scan of the thorax when performed at the same encounter as the CTA Chest which is billed on line 2 of this claim. Received an order for both the CTA Chest and CT Thorax; and an unauthenticated handwritten note documenting "order changed from CTA heart because of irregular heartbeat. <Physician> was notified." Received a consult note documenting the plan to order an echo and CTA of the chest. No documentation of intent to order the CT scan and documentation is insufficient to support the medical necessity of both the CT scan of the thorax and CTA Chest performed on the same day Missing the physician order or clinical documentation of intent of ordering the billed hemoglobin; glycosylated (A1C), comprehensive metabolic panel (CMP), complete blood count (CBC) with differential, thyroxine; total, albumin; urine, microalbumin, quantitative, urinalysis automated with microscopy, and uric acid; blood. Received laboratory reports, unsigned lab requisition, and progress notes that support medical necessity. Requested additional documentation from the ordering provider and received duplicate documentation. Billed amitriptyline, benzodiazepines, desipramine, imipramine, nortriptyline, quantitation of drug, urinalysis, automated without microscopy, amphetamine or methamphetamine, amphetamine or methamphetamine with modifier 91, and cocaine or metabolite. Missing physician's order, intent to order and medical necessity for billed tests. Submitted an unsigned requisition form and results. Provider billed for lab tests free thyroxine, Vitamin B-12, and folic acid level for 8/8/13 and submitted copy of requisition and results. (1) Missing copy of physician's order for tests, or documentation, such as might be found in progress notes, describing intent to obtain the tests. (2) Missing copy of documentation describing medical necessity for tests, such as might be found in physician's progress notes. Billed the following for multiple dates of service: CPT 77263 therapeutic radiology treatment planning complex, CPT 77290 therapeutic radiology simulation-aided field setting; complex, CPT 77418 intensity modulated treatment delivery (IMRT), single or multiple fields per treatment session, and CPT 77421 stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy. Missing the following documentation; 1) documentation that includes the therapeutic radiology treatment planning; complex, 2) therapeutic radiology simulation-aided field setting; complex; 3) the physician signed, dated documentation that includes the beneficiary name and includes, documentation of the intensity modulated treatment delivery and 4) documentation of the stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy billed. Initially received consult note, treatment sheets with no beneficiary name and initials only of RTTs, treatment plan, and invalid attestation statement for date span not individual date. Insufficient documentation to support billed services per the governing Local Coverage Determination (LCD) and Medicare guidelines. Provider billed for ultrasound of abdomen (CPT 76705) and submitted copy of report. In response to request for referring provider order and documentation of medical necessity, received a copy of the report and copy of an unsigned progress note for service after the billed date. (1) Missing copy of physician's order or documentation describing intent for test. (2) Missing copy of documentation describing medical necessity for test. Billing for physical therapy (PT) services (therapeutic procedures, manual therapy techniques and ultrasound) for date of service 10/24. Missing a certification of the plan of treatment that includes a date, or a delayed certification that includes a reason for the delay. Received a PT referral; initial PT evaluation with that includes a plan of care (POC); certification of the POC by the referring physician, that is not dated, that includes a fax date of 10/02, however, this is the fax Page 2 of 5
number for the PT not the certifying MD; recertification of the POC after the claim DOS; treatment notes; and therapy log for the DOS that includes billed modalities with total treatment time of 40 minutes, with US indicated as 12 minutes. Insufficient documentation. Billed 90836- psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management (E/M) service. Missing provider duration of time spent with the beneficiary during psychotherapy. Visit note documents a start and end time however the billing provider did not specify if the time was used to perform psychotherapy or performed for CPT 99213, which was billed on line 1 of this claim. Requested additional documentation from the listed billing provider and received duplicate documentation. Billed 90836. Missing; 1) treating physician s authenticated psychotherapy progress note with time duration for therapy documenting therapeutic interventions (such as behavior modification, supportive interaction, and discussion of reality) applied in an attempt to produce therapeutic change; 2) documentation of beneficiary s capacity to participate in, and benefit from psychotherapy per LCD requirement. Documentation received includes visit note that supports E/M service billed on line 1. No psychotherapy service documented to support billed service. Billed CPT 98941-AT, Chiropractic manipulation 3-4 regions. Missing a copy of the initial evaluation/plan of Care and documentation of necessity to support AT modifier. Treatment appears to be maintenance, not acute. Provider billed for CMT to 3-4 regions (98941) for acute condition with modifier AT. Missing initial evaluation with initial treatment plan. Missing objective markers to substantiate that patient was improving in response to treatment. Unable to determine that condition remained acute or that clinical improvement had occurred or would be expected to occur. Maintenance therapy is not covered by Medicare. Billed CPT 98941-AT (chiropractic manipulative treatment (CMT); spinal; three to four regions). Missing: 1) signed and dated initial and re-evaluations with P.A.R.T Exam; 2) Signed and dated initial and subsequent treatment plans related to billed chiropractic services; 3) Need documentation of the regions of the spine that were manually manipulated on billed dates; and 4) Need clarification of the exact location of subluxation(s) of the spine. Submitted documentation included flow sheet, unsigned progress note with no patient identification on the form, ABN, and patient complaint form signed by the beneficiary. Without a treatment plan and documentation of areas of subluxation there is insufficient documentation submitted to support the billed service. Billed epidural steroid injection (CPT 62311, 77003). Missing LCD required documentation criteria: 1) initial evaluation including history and physical examination, diagnosis, pain and disability of moderate to severe degree, 2) documentation of conservative therapies that were tried and failed, 3) pre and post procedure evaluation. Received signed operative report, nursing and anesthesia pre op record, and intra op anesthesia record. No response to request for treating provider clinical records. Received only an unsigned pulmonary function test (PFT) report. Missing MD order or intent to order the pulmonary function test (CPT 91010-Q6) done; missing office visit notes to support medical necessity; missing provider authentication of the PFT report. Incorrect Coding - 21% of total errors Page 3 of 5
Provider billed for trimming 2-4 hyperkeratotic lesions (CPT 11056) and submitted copy of note describing debridement of 5 lesions. Code should be changed to CPT 11057; more than 4 lesions. Patient was diabetic with related peripheral neuropathy and peripheral artery disease with absent dorsalis pedis puls bilaterally. Hyperkeratoses were described as pre-ulcerative. Billed code 99204 requires three of the following three elements; comprehensive history, comprehensive exam, and moderate complexity medical decision making (MDM). Submitted documentation supports down code to 99203 by meeting comprehensive history, detailed exam, and moderate MDM. Billed CPT 99204. Documentation supports a down code to 99202 as billed with Detailed History (Limited Review of Symptoms (ROS)) Expanded Problem Focused Exam (2 body systems), and moderate complexity MDM per 1995 E/M guidelines. Billed 99205 (requires 3/3 key components; comprehensive history, comprehensive exam and high complexity MDM). Documentation supports down code to 99204 with comprehensive history, comprehensive exam and moderate MDM meeting 3/3 of the required key components. Billed 99214 requires 2 out of 3 key components; detailed history, detailed exam, and moderate complexity MDM. Submitted documentation supports down code to 99213 with Expanded Problem Focused History, Expanded Problem Focused exam using 1995 guidelines, and Low Complexity MDM. Billed 99222, requires 3 out of 3 key components comprehensive history, comprehensive exam, and moderate MDM. Submitted documentation supports a down code to 99221 with Detailed History (Limited ROS/No family History), Comprehensive Exam using 1995 E/M guidelines, and Moderate MDM. Submitted is an initial hospital care visit, billed as 99222. Documentation supports changing code to 99232, which requires 2 of the following 3 components: Expanded History, Expanded Exam, and Moderate MDM, with coding of Detailed History, Expanded Exam, and Moderate MDM. Billed is CPT 99223 - Initial hospital care E/M service which requires 3/3 components (comprehensive history, comprehensive exam, high complexity MDM). Documentation supports down code to 99232 which requires 2 of 3 key components (expanded problem focused history, expanded problem focused exam, and moderate MDM). Meets 99232 with comprehensive history, expanded problem focused exam, and moderate MDM per 1995 E/M guidelines. Billed CPT 99223. Documentation supports down code to 99221 with a comprehensive history, detailed exam and MDM of high complexity. This meets 2 and exceeds 1 component for 99221. Billed CPT 99233 requires 2 of 3 components (detailed history, detailed exam, and high complexity MDM). Documentation supports a down code to 99232 as billed with Expanded Problem Focused History and Exam, and Moderate Complexity MDM per 1995 E/M guidelines. Provider billed for CPT 99239 for more than 30 minutes discharge management and submitted copy of discharge summary and progress note. Missing documentation of amount of time spent. Change code to 99238. Billed Emergency Department visit (CPT 99285-UA-25) but no GC modifier. Incorrectly coded and insufficient documentation submitted to support if the billing physician is a Teaching Physician in this setting, and the E/M service provided would need to meet the requirements and be billed with a GC modifier as required in CMS Internet-Only Manual, Publication 100-02, Chapter 15, section 30.2. Page 4 of 5
Submitted is an initial nursing facility care visit, billed as 99305-AI, which requires 3 of the following 3 components: Comprehensive History, Comprehensive Exam, and Moderate MDM. Documentation supports recoding to 99499-AI (Unlisted evaluation and management service) as it fails to meet the minimum requirements for the E/M category billed, with Detailed History, No Exam, and Moderate MDM. Medically Unnecessary Service or Treatment 1% of total errors Missing the lab test result for folic acid; serum, therefore, the venipuncture is not medically necessary. Based on CERT error findings for this quarter, below are educational resources that can assist in avoiding these issues in your practice. CMS Resources Provider Signature Requirements - CMS Internet-Only Manual(IOM), Publication 100-08, Chapter 3, Section 3.3.2.4 Requirements for Ordering and Following Orders for Diagnostic Tests CMS IOM, Publication 100-02, Chapter 15, section 80.6.1 Home Services - CMS IOM, Publication 100-04, Chapter 12, section 30.6.14.1 Teaching Physician Services CMS IOM, Publication 100-04, Chapter 12, section 100 Teaching Physician Services CMS IOM, Publication 100-02, Chapter 15, section 30.2. Coverage of Outpatient Rehabilitation Therapy Services/Definitions/Date IOM, Publication 100-02, Chapter 15, section 220.A and Certification and Recertification section 220.1.3 WPS Medicare Resources Local Coverage Determinations (LCDs) for: Chiropractic Services Epidural and Transforaminal Epidural Injections Psychiatry and Psychology Services Radiation Oncology Including Intensity Modulated Radiation Therapy (IMRT) Routine Foot Care Additional WPS Medicare web page resources: CERT Articles CERT Error Analysis Evaluation & Management Services (under Resources, Provider Specialties/Services) Note: Review results are based on 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