HCCA Clinical Practice Compliance Conference October 11-13, 2015 1 Joette Derricks, MPA, CHC, CPC, FACMPE, CLSSGB Derricks Consulting, LLC October 12, 2015 Disclaimer Healthcare regulations change frequently. The information presented today handouts, supplemental documentation and information (collectively, the “Presentation”) is for general informational purposes only and should not be taken as legal advice or understood to create a legal contract or other covenant or agreement of any kind between the attendee and the presenters. Although the information found in this Presentation is believed to be reliable, no warranty, expressed or implied, is made regarding the accuracy, adequacy, completeness, legality, reliability, or usefulness of any information, either isolated or in the aggregate. The information in the Presentation is supplemental to, and not a substitute for, the AMA CPT-4 Codebook, any federal or state regulations, or payer/carrier contract or policies. There is no guarantee that the use of this material will prevent differences of opinion with payers/carriers/or regulators in payment and/or reimbursement disputes. It is further noted that any and all liability arising from the use of materials or information and/or presented at the seminar is the sole responsibility of the participant, and his/her respective employer(s) who, by their attendance at this Presentation, evidences agreement to hold harmless the aforementioned parties, their employees and affiliates. The Presentation is intended to be used as a teaching “tool”. CPT® Codes are copyright by the American Medical Association. 9/4/2015 Derricks Consulting 2
Transcript
HCCA Clinical Practice Compliance Conference
October 11-13, 2015
1
Joette Derricks, MPA, CHC, CPC, FACMPE, CLSSGB
Derricks Consulting, LLC
October 12, 2015
Disclaimer Healthcare regulations change frequently. The information presented today handouts,
supplemental documentation and information (collectively, the “Presentation”) is for general informational purposes only and should not be taken as legal advice or understood to create a legal contract or other covenant or agreement of any kind between the attendee and the presenters. Although the information found in this Presentation is believed to be reliable, no warranty, expressed or implied, is made regarding the accuracy, adequacy, completeness, legality, reliability, or usefulness of any information, either isolated or in the aggregate.
The information in the Presentation is supplemental to, and not a substitute for, the
AMA CPT-4 Codebook, any federal or state regulations, or payer/carrier contract or policies. There is no guarantee that the use of this material will prevent differences of opinion with payers/carriers/or regulators in payment and/or reimbursement disputes.
It is further noted that any and all liability arising from the use of materials or
information and/or presented at the seminar is the sole responsibility of the participant, and his/her respective employer(s) who, by their attendance at this Presentation, evidences agreement to hold harmless the aforementioned parties, their employees and affiliates. The Presentation is intended to be used as a teaching “tool”.
CPT® Codes are copyright by the American Medical Association.
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Session Objectives
Understand the CERT Program’s purpose and how the results can help physicians fine tune their audits
Explore NCDs/LCDs documentation and coding requirements and the impact insufficient documentation has on revenue
Identify key process deficiencies that can result in a CERT error or a claim denial and how to fix them
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Comprehensive Error Rate Testing (CERT) Program Directive
Improper Payment Measurement in the Medicare Fee-for-Service Program
Amended the Improper Payments Information Act of 2002 (IPIA)
Requires the heads of Federal agencies, including the Department of Health and Human Services (HHS), to annually review programs it administers to improve agency efforts to reduce and recover improper payments
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CERT Program Directive
Identify programs that may be susceptible to significant improper payments
Estimate the amount of improper payments in those programs
Submit the estimates to Congress
Report publicly the estimate and actions the Agency is taking to reduce improper payments
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CERT Program Directive
Payments that should not have been made or payments made in an incorrect amount (including overpayments & underpayments)
Payment to an ineligible recipient
Payment for an ineligible service
Any duplicate payment
Payment for services not received
Payment for an incorrect amount
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CERT Program Design
Original work was performed by OIG and involved a sample of 6,000 claims that were reviewed against all coverage, coding, and payment rules.
CMS took over the responsibility for the improper payment measurement beginning in 2001 Current sample size is 50,000 claims
CERT Program Design Today the CERT program monitors decisions made by
MACs, Part A & B & DME and includes the full range of claims submitted by various provider types
Focus of this Presentation is on physicians including NPs, PAs, and other qualified health care professionals
The CERT program calculates the Medicare FFS program improper payment rate. Any payment that should not have been made or that was
paid at an incorrect amount (including both overpayments and underpayments) is an improper payment
Per CMS the improper payment rate does not measure fraud. It estimates the payments that did not meet Medicare coverage, coding and billing rules
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CERT Program Process
Claim Selection
Medical Record Requests
Review of Claims
Assignment of Improper Payment Categories
Calculation of the Improper Payment Rate
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CERT Program Process Claim Selection
A stratified random sample is taken by claim type:
Part A (excluding acute inpatient hospital services)
Part A (acute inpatient hospital services only)
Part B
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Claims are selected on a semi-monthly basis
The final CERT sample is comprised of claims that were either paid or denied by the MACs
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CERT Program Process
Medical Record Requests
The CERT Documentation contractor requests medical records from the provider that submitted the claim
For some claim types additional documentation requests are also made to the referring provider who ordered the item or service
If no documentation is received within 75 days of the initial request, the claim is classified as a “no documentation” claim and counted as an error
If documentation is received after 75 days of the initial request (late documentation), CERT will still review the claim
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CERT Program Process Review of Claims
Upon receipt of medical records, medical review professionals at the CERT Review Contractor conduct a review of the claim and submitted documentation to determine whether the claim was paid properly
Nurses, medical doctors, and certified coders review the claims
Determinations are made regarding whether the claim was paid properly under Medicare coverage, coding, and billing rules
Improper payment categories are assigned
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CERT Program Process Improper payments are payments made by the
government to the wrong person, in the wrong amount, or for the wrong reason. Although not all improper payments are fraud, and not all improper payments represent a loss to the government
Improper Payment Categories No Documentation Insufficient Documentation Medical Necessity Incorrect Coding Other
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CERT Program Process
Calculation of the Improper Payment Rate
The improper payment amount for each MAC is weighted by its proportion of national total allowed charges
After this weighting is complete, the Medicare FFS improper payment rate is calculated
The findings are projected to the total Medicare FFS claims submitted during the report period
Determinations of overall financial impact are made based upon Medicare FFS expenditures
2014 CERT Program Results Table 7: 2014 Projected Improper Payments (Dollars in Billions) by Type of Error and
Clinical Setting
Examining the types of CERT review errors and their impact on improper payments is
a crucial step toward reducing the improper payment rate in the Medicare FFS
program. Improper payments vary by clinical setting. Insufficient documentation
errors and medical necessity errors are the main drivers of projected improper
payments.
Error Category
DMEPOS
Home
Health
Agencies
Hospital
Outpatient
Departments
Inpatient
PPS
Hospitals
Physician
Services
(All
Settings)
Skilled
Nursing
Facilities
Other
Clinical
Settings
Overall
No
Documentation
$0.03
$0.03
$0.02
$0.03
$0.18
$0.00
$0.00
$0.30
Insufficient
Documentation
$4.71
$8.46
$5.36
$1.41
$5.64
$2.00
$1.92
$29.49
Medical
Necessity
$0.18
$0.84
$0.22
$11.30
$0.06
$0.09
$0.19
$12.87
Incorrect
Coding
$0.01
$0.01
$0.15
$2.19
$2.75
$0.38
$0.12
$5.61
Other
$0.16
$0.06
$0.03
$0.17
$0.21
$0.18
$0.01
$0.82
Total
$5.09
$9.40
$5.77
$15.09
$8.85
$2.65
$2.25
$49.09
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2014 CERT Program Results Table 8: Projected Improper Payments, Overpayments and Underpayments by Top 10 States
(Dollars in Millions)
Overall
Overpayments
Underpayments
Improper
Payment
Amount
Improper
Payment Rate
Improper
Payment
Amount
Improper
Payment Rate
Improper
Payment Amount
Improper
Payment Rate
CA $5,155.1 16.0% $5,033.9 16.0% $121.2 0.0%
TX $4,416.5 15.7% $4,399.1 16.0% $17.4 0.0%
FL $3,631.2 13.9% $3,505.5 13.0% $125.8 1.0%
NY $3,282.1 14.0% $3,015.8 13.0% $266.3 1.0%
IL $2,484.4 14.4% $2,399.5 14.0% $85.0 1.0%
MI $2,049.4 14.9% $1,868.5 14.0% $180.9 1.0%
PA $1,948.4 12.2% $1,888.5 12.0% $59.9 0.0%
OH $1,790.1 13.5% $1,768.8 13.0% $21.3 0.0%
NC $1,657.9 12.7% $1,644.0 13.0% $13.9 0.0%
NJ $1,565.7 14.3% $1,505.1 14.0% $60.6 1.0%
Overall
$49,091.4
13.6%
$47,551.1
13.0%
$1,540.4
0.0%
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2014 CERT Program Results
Table G1: Improper Payment Rates by Provider Type / Type of Error: Part B
Provider Types Billing to Part B
Improper
Payment
Rate
Number of
Claims in
Sample
Type of Error
No Doc
Insufficient
Doc
Medical
Necessity
Incorrect
Coding
Other
Chiropractic 54.1%
718
2.1%
92.2%
4.8%
0.5%
0.3%
Clinical Social Worker 33.9%
114
0.7%
99.3%
0.0%
0.0%
0.0%
Clinical Laboratory (Billing Independently)
33.8%
2,332
0.2%
92.2%
6.9%
0.5%
0.1%
Critical Care (Intensivists) 32.6%
62
0.0%
47.5%
0.0%
33.8%
18.7%
Physical Therapist in Private Practice
29.5%
510
0.1%
95.7%
0.0%
1.7%
2.5%
Allergy/Immunology 27.7%
35
0.0%
77.1%
0.0%
22.9%
0.0%
Occupational Therapist in Private Practice
27.4%
42
0.0%
100.0%
0.0%
0.0%
0.0%
Clinical Psychologist 24.4%
152
0.0%
93.9%
0.0%
3.5%
2.6%
Psychiatry 21.0%
278
0.0%
59.9%
0.5%
39.4%
0.2%
Neurology 18.5%
198
1.2%
18.1%
0.0%
56.7%
24.1%
Endocrinology 17.3%
64
2.5%
55.9%
0.1%
40.4%
1.1%
Pulmonary Disease 16.5%
311
2.5%
46.5%
0.0%
48.0%
3.0%
Internal Medicine 16.3%
2,080
2.5%
55.3%
0.3%
41.9%
0.0%
Physical Medicine and Rehabilitation
14.9%
163
0.0%
56.4%
0.0%
43.6%
0.0%
Nephrology 14.6%
304
4.6%
54.5%
0.0%
40.9%
0.0%
Cardiology 14.4%
1,097
3.4%
57.8%
1.7%
35.7%
1.4%
Otolaryngology 13.5%
81
7.4%
62.5%
0.0%
27.1%
2.9%
Interventional Pain Management 13.3%
92
0.0%
97.6%
0.1%
2.3%
0.0%
Family Practice 13.2%
964
3.2%
53.1%
0.6%
42.6%
0.4%
Podiatry 13.1%
245
3.4%
61.1%
2.5%
22.0%
11.1%
Infectious Disease 12.9%
120
0.0%
45.4%
0.0%
54.6%
0.0%
Diagnostic Radiology 12.6%
1,324
0.2%
98.5%
0.0%
0.2%
1.2%
Emergency Medicine 12.5%
475
0.0%
32.5%
0.0%
65.5%
2.0%
Ambulance Service Supplier 12.4%
562
0.0%
81.3%
12.6%
6.1%
0.0%
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2014 CERT Program Results Table H5: Type of Services with Upcoding
Errors: Part B
Part B Services
Upcoding Errors
Improper
Payment
Rate
Projected
Improper
Payments
95%
Confidence
Interval Hospital visit - initial
20.8%
$605,072,311
19.1% - 22.4%
Office visits - established 4.0%
$575,057,387
3.4% - 4.5%
Hospital visit - subsequent 8.2%
$466,223,892
7.4% - 9.1%
Office visits - new 13.2%
$353,292,535
11.1% - 15.2%
Emergency room visit 9.7%
$210,772,375
7.8% - 11.5%
Nursing home visit 9.0%
$174,879,462
7.4% - 10.7%
Hospital visit - critical care 13.6%
$136,940,955
10.4% - 16.8%
Ambulance 0.8%
$43,530,485
0.3% - 1.2%
Dialysis services (Medicare Fee Schedule) 3.8%
$28,873,775
2.3% - 5.3%
Eye procedure - cataract removal/lens insertion
1.0%
$18,172,660
(0.7%) - 2.6%
Specialist - ophthalmology 0.6%
$14,498,244
(0.1%) - 1.2%
Specialist - other 1.7%
$12,041,203
(1.0%) - 4.5%
Home visit 3.7%
$9,303,538
(0.5%) - 7.8%
Lab tests - blood counts 2.9%
$8,999,752
1.8% - 4.1%
Minor procedures - other (Medicare fee schedule)
0.2%
$6,575,619
0.0% - 0.4%
Other drugs 0.1%
$3,228,939
(0.0%) - 0.1%
Standard imaging - other 1.2%
$3,216,994
(1.1%) - 3.6%
Advanced imaging - MRI/MRA: other 0.3%
$3,045,187
0.2% - 0.3%
Specialist - psychiatry 0.2%
$2,054,378
(0.1%) - 0.4%
Chiropractic 0.3%
$1,590,914
0.0% - 0.5%
All Other Codes 0.0%
$6,058,433
0.0% - 0.0%
Overall 3.0%
$2,683,429,038
2.7% - 3.2%
Upcoding refers to billing a higher level service or a service with a higher payment than is supported by the medical record documentation.
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2014 CERT Program Results Table I1: Service Specific Overpayment Rates: Part B
Part B Services
Number of
Claims in
Sample
Number of
Lines in
Sample
Dollars
Overpaid in
Sample
Total Dollars
Paid in
Sample
Projected
Dollars
Overpaid
Overpayment Rate
Initial hospital care (99223)
664
667
$40,026
$119,431
$652,422,003
33.8%
Subsequent hospital care (99233)
856
1,309
$36,426
$121,533
$542,582,860
29.7%
Office/outpatient visit est (99214)
900
902
$5,779
$84,872
$394,798,829
5.6%
Subsequent hospital care (99232)
780
1,318
$11,710
$87,343
$341,726,342
12.7%
Therapeutic exercises (97110)
370
413
$5,915
$18,341
$299,395,466
33.1%
Critical care first hour (99291)
315
411
$26,616
$83,548
$277,395,431
29.0%
Emergency dept visit (99285)
223
223
$6,038
$34,536
$269,944,244
18.8%
Ambulance BLS(A0428)
147
159
$6,071
$30,710
$256,291,998
20.6%
Office/outpatient visit est (99213)
579
590
$1,735
$36,874
$233,168,881
4.1%
Office/outpatient visit est (99215)
272
272
$6,446
$35,173
$204,583,565
19.4%
Office/outpatient visit new (99204)
223
223
$5,335
$31,371
$204,463,702
18.1%
Ambulance ALS Level 1-emergency (A0427)
194
194
$8,103
$70,897
$198,368,639
11.4%
Chiropractic manipulation (98941)
466
572
$9,435
$17,034
$184,787,446
52.7%
Initial hospital care (99222)
255
255
$7,208
$30,394
$163,290,635
22.9%
Ground mileage (A0425)
438
451
$4,398
$31,920
$139,845,535
13.7%
Office/outpatient visit new (99203)
112
112
$1,535
$9,381
$133,279,140
15.4%
Manual therapy (97140) 323
361
$3,264
$9,769
$128,882,754
33.4%
No HCPCS Label 430
606
$7,215
$41,522
$127,304,393
8.9%
Office/outpatient visit new (99205)
149
149
$5,467
$26,187
$107,770,801
21.8%
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2014 CERT Program Results Table J1: Service-Specific Underpayment Rates: Part B
Part B Services
Number of
Claims in
Sample
Number of
Lines in
Sample
Dollars
Underpaid
in Sample
Total Dollars
Paid in
Sample
Projected
Dollars
Underpaid
Underpayment Rate
Office/outpatient visit est (99212)
153
165
$524
$5,959
$56,964,603
9.0%
Office/outpatient visit est (99213)
579
590
$394
$36,874
$52,732,451
0.9%
All Codes W Less Than 30
Claims
4,921
8,175
$452
$890,672
$21,264,813
0.1%
Subsequent hospital care (99231)
187
309
$335
$10,699
$13,960,526
4.3%
Nursing fac care subseq (99307)
44
45
$121
$1,737
$9,146,506
8.1%
Office/outpatient visit est (99214)
900
902
$74
$84,872
$6,926,956
0.1%
Office/outpatient visit new (99203)
112
112
$52
$9,381
$6,260,324
0.7%
Office/outpatient visit new
(99202)
55
55
$68
$3,023
$4,609,766
3.1%
Office/outpatient visit est (99211)
108
113
$138
$1,581
$4,040,042
4.1%
Subsequent hospital care (99232)
780
1,318
$101
$87,343
$4,035,889
0.1%
Emergency dept visit (99283) 72
72
$102
$3,775
$3,797,612
2.0%
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2014 CERT Program Results Table K1: Claims in Error Part B
Variable
Number of
Claims Reviewed
Number of Claims Containing Errors
Percent of Claims Containing Errors
HCPCS
All Codes W Less Than 30 Claims
8,175
1,463
17.9%
Chiropractic manipulation (98941)
572
279
48.8%
Comprehen metabolic panel (80053)
557
133
23.9%
Initial hospital care (99223)
665
361
54.3%
No HCPCS Label
606
147
24.3%
Office/outpatient visit est (99213)
590
49
8.3%
Office/outpatient visit est (99214)
902
131
14.5%
Routine venipuncture (36415)
773
168
21.7%
Subsequent hospital care (99232)
1,296
213
16.4%
Subsequent hospital care (99233)
1,263
734
58.1%
Other
25,579
6,970
27.2%
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2014 CERT Improper Payment Data by Claim
The dataset includes detailed information on Medicare FFS claims that underwent CERT medical review for the FY 2014 report period (claims submitted July 1, 2012 through June 30, 2013.) These claims were used to calculate the FY 2014 Medicare FFS improper payment rate.
Part CID Claim Line Item NumberSpan NumberHCPCS Procedure CodeType of BillDRG Diagnosis CodeProvider Type Type of ServiceService From DateService Through DateError Code Review Decision
1. Part B 1282248 1 1 G0442 V791 Internal MedicineOther - Medicare fee schedule11/29/2011 11/29/2011 25 - Medical NecessityDisagree
1. Part B 1282249 1 1 G0439 25060 General PracticeSpecialist - other6/29/2012 6/29/2012 21 - Insufficient DocumentationDisagree
1. Part B 1282249 2 1 G0403 25060 General PracticeOther tests - EKG monitoring6/29/2012 6/29/2012 - Agree
1. Part B 1282249 3 1 82962 25060 General PracticeLab tests - glucose6/29/2012 6/29/2012 - Agree
1. Part B 1282249 4 1 81002 25060 General PracticeLab tests - urinalysis6/29/2012 6/29/2012 21 - Insufficient DocumentationDisagree
1. Part B 1282249 5 1 G0444 25060 General PracticeOther - Medicare fee schedule6/29/2012 6/29/2012 - Agree
1. Part B 1282250 1 1 G0442 V791 Internal MedicineOther - Medicare fee schedule7/9/2012 7/9/2012 - Agree
1. Part B 1282251 1 1 G0439 V700 Internal MedicineSpecialist - other4/23/2012 4/23/2012 - Agree
1. Part B 1282251 2 1 G0446 40290 Internal MedicineOther - Medicare fee schedule4/23/2012 4/23/2012 - Agree
1. Part B 1282251 3 1 93005 40290 Internal MedicineOther tests - electrocardiograms4/23/2012 4/23/2012 - Agree
1. Part B 1282252 1 1 G0438 V700 Family PracticeSpecialist - other6/29/2012 6/29/2012 21 - Insufficient DocumentationDisagree
1. Part B 1282252 2 1 G0444 V700 Family PracticeOther - Medicare fee schedule6/29/2012 6/29/2012 60 - Incorrect Coding Disagree
1. Part B 1282252 3 1 G8448 V700 Family PracticeSpecialist - other6/29/2012 6/29/2012 - Agree
1. Part B 1282252 4 1 3288F V700 Family PracticeUndefined codes6/29/2012 6/29/2012 - Agree
1. Part B 1282252 5 1 1100F V700 Family PracticeUndefined codes6/29/2012 6/29/2012 - Agree
1. Part B 1282252 6 1 1036F V700 Family PracticeUndefined codes6/29/2012 6/29/2012 - Agree
1. Part B 1282253 1 1 G0444 V790 Internal MedicineOther - Medicare fee schedule3/27/2012 3/27/2012 - Agree
1. Part B 1282254 1 1 G0436 3051 Family PracticeAmbulatory procedures - other7/12/2012 7/12/2012 21 - Insufficient DocumentationDisagree
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MAC Jurisdiction Data by Specialty CERT Identified Errors by Provider Specialty
J5 MAC Top Ten Provider Specialties by Dollars in Error
The 10 provider specialties in the chart below accounted for 84.93% of the total dollars in error for WPS
CERT Error Examples by Denial Reason Internal Medicine - Specialty 11
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MAC Jurisdiction Data by Specialty
21 - Insufficient Documentation
Error Examples How to prevent this type of error
Billed CPT 99232 - Subsequent Hospital Care. Missing medical record documentation supporting billed service. Initially submitted documentation includes a transcribed history and physical and a handwritten interdisciplinary note that is partially legible with no date and a illegible provider signature. A request was made for missing documentation, received in part a letter from provider office stating "progress note for date of service is not available". Insufficient documentation to support billed service.
Medicare regulations require that all medical record entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished.
For progress notes missing a signature, a signature attestation statement can be completed by the performing provider and submitted with the corresponding medical records. For cases of illegible signatures, an attestation or signature log can be used to verify the identity of the author of the medical records. For an Attestation Statement example, refer to the Medical Review (MR) Forms page on our WPS Medicare Website. For more information regarding signature requirements refer to the CMS Internet-Only Manual (IOM), Publication 100-08, Chapter 3, Section 3.3.2.4.
For the B12 Injection (CPT 96372, J3420) missing a valid physicians order including amount to be administered. Received the injection records and physician progress notes. Missing intent to order or order for this service. Records include the lab work, progress notes and administration documentation. The orders included are signed by an RN. This claim is not supported as reasonable and necessary.
B12 injections must be ordered by the treating physician and documented as medically necessary according to Medicare requirements. Orders signed by nursing staff alone do not meet Medicare documentation requirements.
For more information on Medicare coverage and coding criteria for these services, refer to the WPS Medicare Local Coverage Determination (LCD) for Vitamin B-12 Injections on our LCD web page.
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CERT Errors Related to NCDs/LCDs CERT Errors - Epidural and Transforaminal Epidural Injections
WPS Medicare received notice from the CERT Contractor of errors assessed due to insufficient documentation
for CPT code 64483 (Injection(s) s, anesthetic agent and/or steroid, transforaminal epidural, with imaging
guidance (fluoroscopy or CT); lumbar or sacral, single level). Included in the CERT contactor's comments for
two different claim submissions, are the following comments:
Case 1
Missing documentation to support use of conservative therapies prior to administration of injection on
04/14/2011, and rendering physician's signature on the provided follow-up telephone call dated
04/22/2011. Of note, this record of phone call does report the beneficiary's current pain level and is
signed by the CMA.
Case 2
Provider submitted copy of physician's order and procedure report for transforaminal epidural injection
and eipdurography in support of billed services for 4/29/11. However, missing is documentation of
medical necessity for the procedure, as required by LCD. Provider submitted a copy of the History
and Physical; however, it was not signed by physician and the form did not include physical exam,
assessment, or plan entries. A Pain Management Information form was submitted; however, the form
was not signed, thus we are unable to determine that entries were those of billing physician.
If you perform and submit any services governed by this LCD to WPS Medicare, please be certain that the
provider's documentation supports the services billed. When responding to a request for documentation, please
include all relevant documentation to support the service billed, and the medical necessity of the service. To
review Epidural and Transforaminal Epidural Injections, LCD L30481 in its entirety, please refer to the Local
Coverage Determinations (LCD) Policy page.
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CERT Errors Related to NCDs/LCDs Documenting Time in Medical Records
WPS Medicare has noted Comprehensive Error Rate Testing (CERT) errors assessed due to missing
documentation of time spent with the beneficiary for Individual Psychotherapy and Critical Care services,
missing treatment time for Physical Medicine and Rehabilitation and missing the total duration of time spent for
final Hospital Discharge of a patient. Medicare may request a refund of any payment made for time not
documented appropriately.
Individual Psychotherapy Services
Because reimbursement of individual psychotherapy services is based on face-to-face time spent with the
patient, practitioners are required to document in the medical record the time spent with the patient and bill the
code that accurately reports the service performed. For further guidance on the proper billing and
documentation of these services, refer to WPS Medicare's Local Coverage Determination (LCD) L30489 -
"Psychiatry and Psychology Services".
Critical Care Services
Critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s)
shall document the total time that critical care services were provided. The duration of critical care services to
be reported is the time the physician spent evaluating, providing care and managing the critically ill or injured
patient's care. That time must be spent at the immediate bedside or elsewhere on the floor or unit so long as
the physician is immediately available to the patient.
For further guidance on the proper billing and documentation of these services, refer to the CMS Internet-Only
Manual (IOM), Publication 100-04, Chapter 12, section 30.6.12 - Critical Care Visits and Neonatal Intensive
Care (Codes 99291-99292).
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HCCA Clinical Practice Compliance Conference
October 11-13, 2015
15
CERT Errors Related to NCDs/LCDs CERT Error Findings - Hyaluronan Injection
WPS Medicare recently received a CERT error finding for an intra-articular injection of the drug Hyaluronan
(Orthovisc®) (Current Procedural Terminology (CPT) codes 20610 and J7324). According to the CERT
reviewer, the medical records submitted did not support the diagnosis and medical necessity of the treatment
according to Local Coverage Determination (LCD) requirements.
Per LCD L30149 - Intra-articular injections of Hyaluronan, documentation in the patient's medical record must
show the patient failed to respond adequately to conservative nonpharmacological therapy (exercise or
physical therapy, weight loss if appropriate) and a past history of treatment with analgesics and a radiological
exam to support the diagnosis of osteoarthritis.
Additionally, if subsequent courses of treatment are given, medical records must support the effectiveness of
the prior treatment and must clearly establish reduction of patient symptomatology and medication usage.
Providers must indicate that documentation is available upon request and must respond timely to any request
for the documentation. Medicare contractors will deny as not medically necessary any claim submitted without
supporting evidence in the medical record.
Please visit the Policy portion of the website to review the Local Coverage Determination (L30149) which
covers this topic.
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CERT and Signatures
Insufficient documentation errors identified by the CERT Review Contractor may include:
Unauthenticated medical records – no provider signature, no supervising signature, illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures
No documentation of intent to order services and procedures – incomplete or missing signed order or progress note describing intent for services to be provided
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HCCA Clinical Practice Compliance Conference
October 11-13, 2015
16
CERT and Physician’s Orders An “order” is a communication from the treating physician/practitioner requesting that a
diagnostic test be performed for a beneficiary. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed. Keep in mind that while a request to a laboratory does not require a signature, there must be a signature in at least one of two places – either on the office note in which the intent to order the test was clearly documented, or on the requisition or lab order slip.
Documents that may serve as an order or intent: A written and signed document from the treating physician, hand-delivered, faxed or
mailed to the testing facility Properly signed progress note indicating reason and test desired Email from treating physician to testing facility requesting test and reason for such. If
email used as intent/order the email would need to be properly signed by the requesting physician.
Telephone call documented by treating physician and testing facility in the patient’s medical record. If a telephone order is used as intent/order, the phone log/telephone order must be properly signed by the requesting physician.
Orders may conditionally request additional or sequential tests if the results of the initial test yields a certain value predetermined by the treating physician.
