Quarterly CERT Error Findings Report WPS GHA Part A J8 MAC ~ Indiana and Michigan ~

Transcription

1 Quarterly CERT Error Findings Report WPS GHA Part A J8 MAC ~ Indiana and Michigan ~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed April 1, 2017, through June 30, 2017, for Part A J8 MAC 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 - 45% of total errors Missing: the inpatient admission orders and certification; the complete physician orders for 9/6/2016-9/10/16; the physician History &Physical (H&P); the physician progress notes; Medication Administration Record (MAR); the lab, EKG, and radiology reports; the discharge summary; the coding summary; the physical therapy (PT), occupational therapy (OT), speech language pathology (SLP) evaluations and progress notes (if ordered); and the emergency department records. CERT received orders for.9 NSS 10 cc syringes; POC; patient education; user key; telemetry strips; pre-hospital EMS report; TTE report; duplicates. Per the Social Security Act (SSA) 1862(a)(1)(A); the CMS Internet Only Manual (IOM) Publication , Chapter 1, 110 (Provider retention of Health Insurance Records) and 42 CFR 424.5(a) (6) (Sufficient information to determine whether payment is due) there is insufficient documentation to support the billed inpatient admission for Date of Service (DOS) 9/6/2016 9/10/2016. Missing the clinical documentation supporting the necessity of the Diagnostic Mammography billed for 08/04/2016. CERT received: the physician's note dated 07/27/2016 supporting intent for a Screening Mammography; an order dated 07/27/2016 for a Screening Mammography; an order dated 08/04/2016 for a Diagnostic Mammography; a signed report of Diagnostic Mammography dated 08/04/2016, which documented a history of benign right core biopsy. Per the SSA 1862(a)(1)(A), 42 CFR 424.5(a)(6) (Sufficient information to determine whether payment is due), 42 CFR (d)(2)(I) (medical necessity in the record), the IOM Publication Chapter 18, 20.B (Diagnostic Mammogram) and the IOM Publication Chapter 18, 20.2 (HCPCS and Diagnosis Codes for Mammography Services), the submitted documentation is insufficient to meet Medicare requirements. Missing the individualized updated treatment plan signed by physician and the physician's order for group therapy sessions for 6/16/2016-6/30/2016. CERT received the group therapy notes for 6/16/2016-6/30/2016. Per the SSA 1862(a)(1)(A) and Local Coverage Determination (LCD) L34616: Psychiatry and Psychology Services, revision effective date 1/1/2016, the submitted documentation does not meet Medicare and governing LCD requirements. Missing a valid physician s standing order or intent to order, that includes frequency parameters, for the Prothrombin Time and an authenticated physician s clinic visit/progress note that supports the need for and/or reason for ordering the Prothrombin Time. CERT received a standing order for PT/INR that is missing frequency parameters, and the Lab results. Per the SSA 1862(a)(1)(A), 42 CFR 424.5(a)(6) (Basic conditions, sufficient information), and the IOM Publication , Chapter 6, 20.5 (Outpatient Therapeutic Services), the submitted documentation is insufficient to support the billed service per Medicare requirements. A note submitted in response to the additional documentation request states, We did not see this patient or have any labs done on the requested date you are asking about. Missing documentation which supports the medical reason and the plan to order the lab test for Infectious Agent Detection by Nucleic Acid (DNA or RNA), Clostridium Difficile, for billed date of service 07/23/2016. Page 1 of 6

2 CERT received a Lab report for 7/23/2016, and an electronic order not authenticated by physician. Per the SSA 1862(a)(1)(A), 42 CFR 424.5(a)(6) (Conditions for Medicare payment-sufficient Information) and the IOM Publication , Chapter 15, 80 (Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests), the submitted documentation does not meet Medicare requirements for payment. Missing a copy of the Anticoagulation Clinic Warfarin Dosing Protocol, an authenticated coumadin clinic note, and specific documentation of intent for lab work. CERT received a progress note which had no authentication by the author. A portion of the lower right hand side of the note was covered with an addressograph stamp which may have covered up the signature portion; the physician standing order/referral which supported medical necessity but had no specific order/intent as reference was made to the Anticoagulation Clinic Warfarin Dosing Protocol; the PT/INR results for date 09/22/2016, a note in response to MRS call stating, "There is(are) no patient encounter(s) for the date(s) of service you requested at this facility/practice." Per the SSA 1862[a][1][A], 42 CFR 424.5(a)(6) )(Conditions for Medicare payment- Sufficient Information), the IOM Publication , Chapter 15, 80 (Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests), there is insufficient documentation in support of the intent for the PT/INR lab test for date 09/22/2016. Medically Unnecessary Service or Treatment 41% of total errors IOM Publication , Chapter 6, A. (Determining Medical Necessity and Appropriateness of Rule, CMS F). Per the CERT Physician Disagree with the inpatient admission as being reasonable and necessary. Procedure, 0DN34ZZ, Release Lower Esophagus, Percutaneous Endoscopic Approach, was medically necessary. The beneficiary had recurrent dysphagia after a previous paraesophageal hernia repair and Nissen fundoplication. The laparoscopic revision is usually done as an outpatient and there were no post-procedure complications to warrant an inpatient admission. Thus, the procedure was justified, but not the inpatient stay. IOM Publication , Chapter 6, A. (Determining Medical Necessity and Appropriateness of Rule, CMS F). Per the CERT Physician- Disagree. Inpatient admission was not reasonable and necessary. The beneficiary s clinical presentation, prognosis and expected treatment did not support the expectation of the need for hospital care spanning two or more midnights. The beneficiary had a medically necessary total thyroidectomy without intraoperative or postoperative complications. Missing a valid physician s standing order or intent to order, that includes frequency parameters, for the Prothrombin Time for billed date of service 10/04/2016; an authenticated physician s clinic visit/progress note that supports the need for and/or reason for ordering the Prothrombin Time; therefore, the related venipuncture is not reasonable and necessary. CERT received a standing order for PT/INR that is missing frequency parameters; Lab results. Per the SSA 1862(a)(1)(A), 42 CFR 424.5(a)(6) (Basic conditions, sufficient information), the IOM Publication Chapter 16, 180 (Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare), and the IOM Publication , Chapter 6, 20.5 (Outpatient Therapeutic Services), the submitted documentation is insufficient to support the billed service per Medicare requirements; therefore, the related venipuncture is not reasonable and necessary. Page 2 of 6

3 IOM Publication , Chapter 6, A. (Determining Medical Necessity and Appropriateness of Rule, CMS F). Per the CERT Physician the Inpatient admission was not reasonable and necessary. The beneficiary was admitted due to increased pain from acute lumbar compression fracture. Her condition was stable and she received two doses of parenteral analgesic. There was no medical necessity for, nor reasonable expectation of at least two midnights at the hospital. IOM Publication , Chapter 6, A. (Determining Medical Necessity and Appropriateness of Rule, CMS F). Per the CERT Physician Inpatient admission was not reasonable and necessary. Documentation supports a beneficiary with a history of dementia, CHF, COPD, IDDM, CKD, and seizure disorder presented with a complaint of frequent falls with ambulatory difficulty. Upon presentation, he was medically stable without focal acute neurological deficits. A work-up was performed in the Emergency Department which was essentially unremarkable. Labs remained near baseline. Imaging excluded traumatic fractures or head injury. Oral meds were continued. The nephrologist recommended conservative medical management of CKD. The beneficiary was able to work with PT on 11/15. He was discharged to a rehabilitation facility. IOM Publication , Chapter 6, A. (Determining Medical Necessity and Appropriateness of Rule, CMS F). Per the CERT Physician The inpatient admission was not reasonable and necessary. Documentation supports a beneficiary with a history of bilateral knee replacements and femur rods had a left posterior subluxation of her total knee arthroplasty s/p fall on 11/3/2016. She re-presented on 11/4/2016 to the emergency room with complaint of impaired mobility despite wearing a knee immobilizer. Upon presentation she was medically stable and complained of pain with weight bearing. Imaging excluded broken hardware, non-union, hip or knee fracture. The beneficiary's pain was well controlled with oral agents. The orthopedist recommended continued knee immobilizer and PT. Wrong Discharge Status Code 7% of total errors CERT Disagrees with the discharge disposition 06-Home with Home Health as coded by the facility. The discharge disposition should be 03-Skilled Nursing Facility (SNF). Discharge disposition confirmed in Common Working File (CWF). CERT Agrees with the facility coded DRG 551 per Official ICD-10-CM Coding Guidelines for Hospitals and available medical record documentation. No change of POA indicators. CERT received the complete medical record. Per the SSA 1862(a) (1) (A), the IOM Publication , Chapter 6, (Medical Review of Inpatient Hospital Claims/ Screening Instruments) and A (IPPS Hospital: Determining Medical Necessity and Appropriateness of Admission). The inpatient admission is reasonable and necessary. CERT disagrees with the discharge disposition 06-Home with Home Health as coded by the facility. The discharge disposition should be 01-Home. The disposition was confirmed in CWF. CERT Agrees with facility coded DRG 190 per Official ICD-10-CM Coding Guidelines for Hospitals and available medical record documentation. No change of POA indicators. CERT received the complete medical record. Per the SSA 1862(a) (1) (A), the IOM Publication , Chapter 6, (Medical Review of Inpatient Hospital Claims/ Screening Instruments) and A (IPPS Hospital: Determining Medical Necessity and Appropriateness of Admission). The inpatient admission was reasonable and necessary Page 3 of 6

4 CERT disagrees with the discharge disposition 06- Home Health as coded by the facility. The discharge disposition should be 01-Home. Per the submitted documentation in discharge summary and flowsheets, the beneficiary was discharged home. CERT received the complete medical record. Per the SSA 1862(a) (1) (A), the IOM Publication Chapter 6, (Medical Review of Inpatient Hospital Claims/ Screening Instruments) and A (IPPS Hospital: Determining Medical Necessity and Appropriateness of Admission). The Inpatient admission was reasonable and necessary. DRG Wrong Diagnosis Code 3% of total errors The principal diagnosis should be J18.9, (Pneumonia, unspecified organism). The DRG is changed from billed DRG 202 to DRG 193. Per the submitted documentation progress notes reflect possible PNA. Discharge summary listed a final diagnosis of pneumonia and noted "it was felt it had a combination of pneumonia with acute pulmonary edema." CERT received the Discharge summary; the physician Emergency Department note; Nursing notes; Progress notes; Consults; Telemetry; Labs; MAR; Admit order. Per the SSA 1862(a)(1)(A); the IOM Publication , Chapter 6, (Medical Review of Inpatient Hospital Claims/ Screening Instruments); ICD-10-CM Guidelines for Hospitals, Section II, Selection of Principal Diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS). The inpatient admission was reasonable and necessary. The secondary diagnosis should be E43, (Unspecified severe protein-calorie malnutrition). The DRG is changed from billed DRG 372 to DRG 371. ICD-10-CM Official Guidelines for Coding and Reporting, Section III, Reporting Additional Diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS), item 11-b as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. The discharge summary noted beneficiary had severe proteincalorie malnutrition with an albumin of 1.7 likely due to persistent diarrhea along with poor oral intake. CERT received the complete Inpatient Medical Record. Per the SSA 1862(a)(1)(A) ; the IOM Publication , Chapter 6, (Medical Review of Inpatient Hospital Claims/ Screening Instruments); ICD-10- CM Guidelines for Hospitals, Section III, Reporting Additional Diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS). The inpatient admission is reasonable and necessary. DRG Wrong Procedure Code 1% of total errors The procedure code should be 02HK3KZ, (Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach), with the removal of code 0JH60PZ, (Insertion of Cardiac Rhythm Related Device into Chest Subcutaneous Tissue and Fascia, Open Approach). The DRG is changed from billed DRG 245 to DRG 226. Per the ICD-10-PCS Official Guidelines for Coding and Reporting, procedure code 02HK3KZ is appropriate. Per the Operative report a venotomy was performed and lead was placed in the cephalic vein without difficulty, this was placed in the RV apex. CERT received the complete medical record. Per the SSA 1862(a) (1) (A), the IOM Publication Chapter 6, (Review of Procedures Affecting the DRG), and ICD- 10-PCS Official Guidelines for Coding and Reporting. The inpatient admission and single chamber ICD was reasonable and necessary. Service Incorrectly Coded 1% of total errors The provider billed 1 Unit of Service (UOS) for CPT J1442 (Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram). The submitted documentation supports a change in units of service from 1 UOS to 300 UOS. CERT received the physician's order for "Neupogen 300 mcg SQ on 4/7, 8, 9, 10, 11"; the signed physician's office note dated 04/19/2016 supporting medical necessity; and the Medication administration record for the billed DOS that documents the administration of Neupogen 300 mcg by SQ injection. Per the SSA 1862(a)(1)(A), the IOM PUblication , Chapter 4, 20.4 (Reporting Units of Service), and CPT Page 4 of 6

5 Submitted physician's order and medication administration record support a change in UOS for CPT J1442 to 300 UOS. The Billed Neupogen is Reasonable and Necessary for this beneficiary on chemotherapy for treatment of esophageal cancer. Invasive Procedure Not Medically Necessary 1% of total errors The procedure code 0D164ZA, (Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach), is removed from the coding sequence. Per the CERT Physician, procedure code 0D164ZA is not reasonable and necessary. The DRG is changed from billed DRG 981 to DRG 205. CERT received the complete inpatient medical record and a duplicate copy of the operative report. Per the SSA 1862(a)(1)(A), the IOM Publication , Chapter 6, (Review of Procedures Affecting the DRG), and the IOM Publication , Chapter 1, (Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity). Per the CERT Physician Missing clinical documentation of failed conservative preoperative weight-loss treatment. The Inpatient admission was reasonable and necessary. The beneficiary had postoperative complications including fever, hypoxemia, and GI bleeding after undergoing an elective laparoscopic gastric bypass surgery. No Documentation was Received 1% of total errors. Missing: Medical record documentation to support that the billed 12-Lead EKG for date of service 11/02/2016 was provided and was reasonable and necessary per Medicare requirements. CERT received: the CERT cover sheet; a note from the provider stating, in part, There are no available records for the requested DOS of 11/02/2016. Per the SSA 1862(a)(1)(A) and 42 CFR 424.5(a)(6) (Basic conditions, sufficient information), no medical records were received from the billing provider to support the billed 12- Lead EKG and no reason was given for the reimbursement to Medicare for this service. Based on CERT error findings for this quarter, below are educational resources that can assist your facility in avoiding these issues. CMS Resources Outpatient Therapeutic Services CMS IOM Publication , Chapter 6, Section 20.5 Requirements for Ordering and Following Orders for Diagnostic Tests CMS IOM Publication , Chapter 15, Section 80 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare CMS IOM Publication , Chapter 16, Section 180 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, National Coverage Determination (NCD) CMS IOM Publication , Chapter 1, Section Provider Retention of Health Insurance Records CMS IOM Publication , Chapter 1, Section 110 Reporting Units of Service -- CMS IOM Publication , Chapter 4, Section 20.4 HCPCS and Diagnosis Codes for Mammography Services CMS IOM Publication , Chapter 18, Section 20.2 Diagnostic Mammogram CMS IOM Publication , Chapter 18, Section 20.B Medical Review of Inpatient Hospital Claims/Screening Instruments CMS IOM Publication , Chapter 6, Sections IPPS Hospital: Determining Medical Necessity and Appropriateness of Admission CMS IOM Publication , Chapter 6, Section A Page 5 of 6

6 Review of Procedures Affecting the DRG CMS IOM Publication , Chapter 6, Section CMS TDL Inpatient Hospital Interim Medical Review Guidelines, March 18, 2014 (IPPS Final Rule, CMS-1599-F) WPS GHA Resources Local Coverage Determinations (LCDs) for: Psychiatry and Psychology Services (L34616) WPS GHA Web Page Resources Training Medical Review Provider Specialties/Services 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 6 of 6