Business Briefs: “Heads-Up” from the CERT Documentation Contractors’ Reports

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  In keeping with the “Audit” theme of this issue of Today’s Wound Clinic, this month’s column will focus on some of the wound care related Medicare claims processing reports that have been generated by the Comprehensive Error Rate Testing (CERT) Program. Ever since November of 2003, the Centers for Medicare & Medicaid Services (CMS) has employed CERT Documentation Contractors (CDCs) to help Medicare reduce the amount of improper payments by randomly sampling claims and determining if the claims submission and payment was correct. The CERT program measures, and works to improve, the quality and accuracy of claim submissions and detects local, regional, and national error rate patterns. The CDCs conduct post payment reviews of claims after Medicare payment has been made. By identifying and addressing coding and coverage billing errors, CMS hopes to reduce payment errors.

  The CDCs do not develop or apply their own coverage, payment, or billing policies. Instead the CDCs use the following references when performing their post payment claims reviews:
    • Medicare regulations
    • Billing instructions
    • National Coverage Determinations (NCDs)
    • Coverage provisions in interpretive manuals
    • The respective Medicare claims processing contractor’s Local Coverage Determinations (LCDs)

  The CDCs select a random sample of claims each reporting period. Then they request, from the health care providers, the medical records pertinent to the selected claims. The CDCs review the claims and associated medical records to determine if proper payment was made. If documentation does not comply with the Medicare coding, payment, and coverage rules, OR if the requested Medicare records are not submitted, the CDCs consider that as a paid claims error.

  To better understand the causes of errors, the CDCs calculate and publish a:
    • Paid Claims Error Rate (percentage of total dollars that all Medicare fee-for-service contractors erroneously paid or denied (indicator of how claim errors in the Medicare fee-for-service program impact the Medicare Trust Fund)
    • Service Specific Error Rate
    • Provider Type Error Rate
    • Provider Compliance Error Rate (measures how well providers prepared claims for submission: indicator of how well the Medicare contractors are educating the providers)

  Example: The national Medicare Fee-For-Service error rate for the November 2009 reporting period was 7.8%, which recouped $24.1 billion dollars to the Medicare Trust Fund.

  You may be asking yourself “Why do I need to understand what errors the CERT Documentation Contractors are finding in their audits?” The easy answer is: “to get paid correctly the first time a claim is submitted to Medicare.” All wound care providers should use the items listed below and the published CERT errors as a self evaluation tool. If wound care providers take the time to evaluate the billing and documentation routines within their practices, they will help ensure the top errors are not occurring. TrailBlazer Health Enterprises, one of the Medicare contractors, said it best: “Simple care to ensure that each record answers who, what (and how many), where, when, and why, would eliminate most of the errors that the CERT contractors are finding.”

  The top errors found by CERT contractors are:

Medically Unnecessary Services

  o Service not covered by the Medicare contractor that processed the claim
  o Missing/invalid physician orders.NOTE: A valid physician order as required by regulation, interpretive manual or LCD must be in the medical record for all products and services provided, e.g., surgical and medical debridement, application of enzymatic debridement ointment, surgical dressings, negative pressure wound therapy pumps, wound suction pumps, compression products, diabetic shoes, etc.
  o The medical record received did not include sufficient documentation to make a claim payment determination

  NOTE: Even if a valid ICD-9-CM code(s) was submitted, the ICD-9-CM code(s) alone are not sufficient.
    o Provider not eligible/certified; performed service not eligible or out of scope of practice
    o Furnished in an inappropriate setting
    o Documentation does not describe the code billed
    o Documentation does not support the level of services billed
    o Documentation does not support the number of services billed
    o Medical record did not demonstrate that the service defined by the CPT® /HCPCS code or the HCPCS modifier reported had been performed or provided
    o Diagnostic tests were not ordered by the practitioner who was treating the patient.

  NOTE: The medical record must contain evidence of the practitioner’s intent for the test(s) to be performed or contain an explicit order. The practitioner’s legible signature must be included on the medical record.

Lack of Documentation

  o Wound care provider failed to submit medical records request by the CDC within the 75 day limit.

  NOTE: To avoid a “lack of documentation” error, wound care professionals should provide the exact documentation requested by the CDC to support the services billed and paid. Any difficulty procuring the information from a third-party source such as a hospital or skilled nursing facility does not exempt the wound care professional from having to submit the information. Furthermore, faxing the documentation to the CDC is the preferred method of submission. You know that the CDC has successfully received your fax when you receive a faxed confirmation back from them.

Insufficient Documentation

  o Missing/illegible signature of performing wound care professional

  NOTE: Medicare requires the medical record to contain a provider signature or legible identifier for every service reported to Medicare for payment. This includes service/products provided, services/products ordered, and teaching physician services. The medical record may support that the service was medically reasonable and necessary, but the lack of an acceptable signature of the performing physician or other provider makes the claim invalid.
    o Incomplete or missing valid plan of care ( including physician signature and date)
    o Incomplete physical, occupational, or speech therapy medical records
    o Missing results for diagnostic or laboratory test(s)

Incorrectly Coded Services

  o Evaluation and management/clinic visits billed at levels not supported by the medical record
    • Did not meet evaluation and management/clinic visit level requirements
    • Medical decision-making and exam components included but no history component
    • Exam component did not meet the level required
    • History component did not meet the level required
    • Service did not meet the definition of a new patient

  o Qualifying service not reported
    • Billing an add-on code without the primary surgical code

  o Included in payment for another service
    • Part of global surgery package
    • Code pairs identified in National Correct Coding Initiative (NCCI) were ignored when claim was submitted

  o Incorrectly billed drugs and biological units

  NOTE: Be sure to report the number of units administered as included in the HCPCS code description of the product: eg, per square centimeter vs. per piece of skin/dermal substitute

Services Not Performed

  o Incorrect date of service is the primary error

  NOTE: To avoid a “services not performed” error, wound care providers should ensure they are submitting claims with the correct date of service and documenting the correct date of service in their medical record notes.

  o Duplicate claims submitted and incorrectly paid

Reminders

  1. Claim error rates will not decrease without wound care provider involvement in the solution. Therefore, wound care providers must take action to decrease their claim errors.

  2. Wound care providers must understand Medicare’s requirements. Therefore, they should participate in CERT educational opportunities provided by the Medicare contractor that processes their claims. Their Medicare contractor’s Provider Outreach and Education Departments offer seminars, workshops, Web-based training, teleconferences, and excellent articles and job aids to assist providers in correct claim submissions and appropriate documentation.

  3. Providers must understand the reasons for their claim errors by reading the CERT reports released by the Medicare contractor that processes their claims (See Table I) and by the CERT Documentation Contractor: https://www.cms.gov/CERT/

  4. Wound care providers should pay attention to the information that appears on the Remittance Advice. These notices list both Remark Codes and Claim Adjustment Reason Codes, which help wound care providers identify the reason their claims were denied. If wound care providers wish to learn more about the Remittance Advice, they should refer to the CMS MedLearn Article entitled CMS Manual: Understanding the Remittance Advice https://www.cms.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf

  5. To avoid a “service incorrectly coded” error, wound care providers should ensure they are billing the appropriate code for the service being billed.

  6. All Medicare claims must be filed within one calendar year after the date of service. The reference source for this is: https://www.cms.gov/MLNMattersArticles/downloads/MM6960.pdf

Summary

  Wound care providers are encouraged to conduct self audits to identify coverage and coding errors. They should use the CERT claim errors listed above, as well as claim errors from future CDC reports to design their self-audits. To avoid claim errors and repayments, wound care providers must do everything possible to get paid right the first time.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.

1. CPT is a registered trademark of the American Medical Association.