Quarterly CERT Error Findings Report WPS GHA Part B 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 J8 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 74% of total errors Missing: the results of the billed presumptive drug testing, performed in the physician's office. CERT received: the progress note for the billed date of service (DOS) supporting this beneficiary had been treated by this physician in the past, but had not been there for 2 years, and was directed to follow up with the primary care physician for pain management for violation of the pain contract. The plan includes an order for CPT Code G0483 definitive drug testing. A facet joint injection was performed on the same DOS and the beneficiary was given a prescription for Norco for 1 month; CERT also received the results of the definitive drug testing by National Laboratories. Based on the Social Security Act (SSA) 1833(e); 42 CFR 424.5(a)(6) (Sufficient information); The Internet Only Manual (IOM) Publication 100-04, Chapter 1, 110 (Provider Retention of Health Insurance Records). The submitted documentation is insufficient to meet the LCD and Medicare requirements. Missing: a copy of the physician s visit note that established the need for Chronic Care Management, with documentation to support that the beneficiary has two or more chronic conditions expected to last at least 12 months and includes documentation of a discussion of Chronic Care Management with the beneficiary; a copy of the electronic comprehensive care plan with documentation that it was provided to the beneficiary or the beneficiary s caregiver; a copy of documentation that supports the provision of at least 20 minutes of Chronic Care Management (CCM) services for the month billed; and a copy of the patient agreement or consent for CCM services. CERT received: a copy of the home visit note for DOS 08/30/2016; a note from the provider: "...unable to locate a record for...patient;" a note from provider: "...no treatment at this facility for the dates of service you requested..." Based on the SSA 1833(e); CPT 2016; the IOM Publication 100-02, Chapter 15 10 Supplementary Medical Insurance (SMI) Provisions; MLN (Medicare Learning Network) Fact Sheet on CCM services (ICN 909188, May 2015), the documentation is insufficient to meet Medicare and/or the governing National Coverage Determination (NCD)/LCD requirements. Missing: clinical documentation supporting the necessity for the billed definitive drug screen for date of service. CERT received: an unsigned laboratory requisition form which is not detailed for the billed tests; lab results; an authenticated progress note which shows a beneficiary with upper and lower extremity pain and muscle spasms with medication giving moderate relief, is alert and oriented x 3, reporting no side effects, a plan for a urine drug screen (UDS) and an order for a urine drug screen. Based on the SSA 1833(e), 42 CFR 424.5 (a)(6), The IOM Publication 100-02 Chapter 15 80.6.1 (Requirements for Ordering and Following Orders for Diagnostic Tests), and LCD: Drug Testing (L34645), revision effective 08/01/2016, the documentation submitted is insufficient to support this service per the LCD and Medicare guidelines. Missing: documentation which identifies the beneficiary, a treatment plan applicable to the billed date of service, which includes the type, amount, frequency and duration of services to be provided, diagnoses and anticipated goals, to support the billed individual psychotherapy for the date of service. CERT received: an attestation for 06/14/2016 through 08/02/2016; the initial assessment dated Page 1 of 5
06/14/2016, without a beneficiary name; an 08/02/2016 note without a beneficiary name. Based on 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), the IOM Publication 100-02, Chapter 6, 70.1 (Outpatient Hospital Psychiatric Services), and LCD L34616 (Psychiatry and Psychology Services)- effective 01/01/2016, the submitted documentation is insufficient to support Medicare and LCD requirements. Missing: the physician's order for, or documentation of intent to order, the Computed Tomography (CT), Thorax; without contrast material, and the clinical documentation supporting the medical necessity of the study. CERT received a signed report of the CT of the Chest without intravenous (IV) Contrast, and a note written on CERT letter which states "Patient was referred to Borgess Hospital for CT scan of Chest Follow up nodules". Based on the SSA 1833(e), 42 CFR 424.5(a)(6) (Sufficient information to determine whether payment is due), 42 CFR 410.32(d)(2)(I)(medical necessity in the record), 42 CFR 410.32 (a) (ordering diagnostic tests), the IOM Publication 100-02, Chapter 15, 80.6.1 (physician orders for diagnostic tests and intent), the IOM Publication 100-08, Chapter 3, 3.6.2.2 (Reasonable and Necessary Criteria), the IOM Publication 100-04 Chapter 13, 20.1 (Payment for Radiology Services- Professional Component), the submitted documentation is insufficient to meet Medicare requirements. Missing: documentation of 4 or more face-to-face visits by a physician or other qualified health care professional to support the End Stage Renal Disease (ESRD) related services for the month of July 2016. CERT received: RN and LPN notes dated 07/05/2016, 07/07/2016, 07/21/2016, 07/23/2016 and 07/28/2016. Based on the SSA, 1833(e); 42CFR424.5(a)(6) (Sufficient information); the IOM Publication 100-04, Chapter 1, 110 (Provider Retention of Health Insurance Records) and Chapter 8, 140 (Monthly Capitation Payment Method for Physicians Services Furnished to Patients on Maintenance Dialysis); the IOM Publication 100-08, Chapter 3, 3.2.3 (ADR) and CPT 2016, the submitted documentation is insufficient to meet Medicare requirements. Missing: the results of ambulatory continuous glucose monitoring of interstitial tissue fluid, interpretation and report, billed for date of service 6/30/2016. CERT received a progress note dated 6/30/2016, which indicates the beneficiary presented to have Continuous Glucose Monitor (CGM) removed. The note states the CGM was removed and a log sheet of meal and blood glucose readings submitted from the beneficiary; report will be printed for review by the physician, and the beneficiary will receive a phone call or an appointment to review the summary of the 72 hour monitoring, to make adjustments to medication or encouragement of better meal planning; The progress note dated 6/17/2016, indicating the beneficiary is a diabetic with a Hemoglobin A1C of 8.1% with plan for CGM and diabetic class. The progress notes for dates of service 2/29/2016 and 4/14/2016. Based on 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), the submitted documentation is insufficient to support Medicare requirements. Missing: the billing physician's documentation of the interpretation and report of the ophthalmic biometry by partial coherence interferometry with IOL power calculation. CERT received a visit note dated 9/15/2016, which documented nuclear sclerosis OU (surgical intervention planned for OS), Dry AMD OU) and which indicates testing performed for IOL calculation; the result of the biometry both eyes dated 9/15/16, (no physician interpretation); the optometrist's visit note dated 10/19/2016, the IOL Calculation Report dated 09/15/2016 with handwritten note that states "You have this Lenstar alreadyonly billing for the reading of the Lenstar & calculation of Len's right eye on 10/19/16 done by Dr. Hanley." Per the SSA 1833(e), 42 CFR 424.5(a)(6) (Sufficient information to determine whether payment is due), the IOM Publication 100-02, Chapter 15, 80.6.1 (physician orders for diagnostic tests and intent), the IOM Publication 100-02, Chapter 15, 30.A (Physician Services), the submitted documentation is insufficient to meet Medicare requirements. Page 2 of 5
Incorrect Coding 15% of total errors The documentation supports a down code from 99204 to 99202 with an expanded, problem focused history, a comprehensive examination, and medical decision making of moderate complexity based on the documentation submitted. CERT received an authenticated physician progress note dated 09/02/2016 that does not meet the required 3 of 3 key components (Comprehensive History, Comprehensive Examination and Medical Decision Making of Moderate Complexity) for the level of Evaluation and Management (E/M) service billed for the DOS. Per the CPT 2016, 1995 E/M guidelines and the IOM Publication 100-04, Chapter 12, 30.6.1 (Selection of Level of Evaluation and Management Service). The documentation supports a change in code from 99232 (requires 2 of 3 key components: Expanded History, Expanded Examination and Medical Decision Making of Moderate Complexity) to 99231. Based on the documentation submitted the patient is neurologically stable and can be discharged and supports an Expanded History, Problem Focused Examination, and Medical Decision Making of Low Complexity. CERT received: authenticated, electronic visit notes for DOS 08/02/2016, 08/05/2016, and 08/08/2016. Per the SSA 1833(e), the IOM Publication 100-04, Chapter 12, 30.6.1.B (Selection of Level Of Evaluation and Management Service), and CPT 2016 The documentation supports a down code from 99310 to 99308 with an expanded, problem focused history and examination, and medical decision making of low complexity based on the documentation submitted. CERT received: an authenticated physician progress note dated 11/11/2016 that does not meet the required 2 of 3 key components (comprehensive history and examination and medical decision making of high complexity) for the level of E/M billed for the DOS. Based on CPT 2016, the IOM Publication 100-08 Chapter 3 3.3.2.5A (Amendments, Corrections and Delayed Entries in Medical Documentation), 1995 E/M guidelines and the IOM Publication 100-04 Chapter 12 30.6.1 (Selection of Level of Evaluation and Management Service). No Documentation was Received 7% of total errors Missing: the performing provider's inpatient progress notes for the billed dates of service. CERT received: a note stating "This patient has not been seen in our office. No records"; a note stating "There are No Dates of Treatment for the records you have requested". Per the SSA 1833(e), 42 CFR 424.5(a)(6)(sufficient information), CPT 2016, PUB 100-04, Chapter 12 30.6.1 (Selection of Level of Evaluation and Management Service) and the IOM Publication 100-04, Chapter 1 110 (Categories of Health Insurance Records to Be Retained), the submitted documentation is insufficient to support this claim per Medicare guidelines. Missing: the signed mammogram report to support the professional component for bilateral screening mammogram, producing DDI (direct digital image), plus CAD (computer aided detection). CERT received: the provider's handwritten statement on Marion General Hospital fax sheet "... pt was not seen at MGH on 10/14/16..." Based on the SSA 1833(e), 42 CFR 424.5(a)(6)(Information), and the IOM Publication 100-04 Chapter 1 110 (Records), and the IOM Publication 100-03 Chapter 1 220.4 (NCD for Mammograms), there is insufficient documentation submitted to support the billed service per NCD, IOM, and Medicare guidelines. No Response 4% of total errors No medical records were received. Page 3 of 5
Medically Unnecessary Service or Treatment 1% of total errors The billed services are not reasonable and necessary. Missing the lab report to support the billed collection of venous blood by venipuncture for the DOS. CERT received: an attestation statement and an unsigned visit note. 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), the service is not reasonable and 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 Outpatient Hospital Psychiatric Services CMS IOM Publication 100-02, Chapter 6, Section 70.1 Supplementary Medical Insurance (SMI) Provisions CMS IOM Publication 100-02, Chapter 15, Section 10. Physician Services CMS IOM Publication 100-02, Chapter 15, Section 30.A Requirements for Ordering and Following Orders for Diagnostic Tests CMS IOM Publication 100-02, Chapter 15, Section 80.6.1. 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) for Mammograms CMS IOM Publication 100-03, Chapter 1, Section 220.4 Categories of Health Insurance Records to Be Retained CMS IOM Publication 100-04, Chapter 1, Section 110 Monthly Capitation Payment Method for Physicians Services Furnished to Patients on Maintenance Dialysis CMS IOM Publication 100-04, Chapter 8, Section 140 Selection of Level of Evaluation and Management Services CMS Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.1. Payment for Radiology Services Professional Component CMS IOM Publication 100-04, Chapter 13, Section 20.1. Additional Documentation Requests CMS IOM Publication 100-08, Chapter 3, Section 3.2.3. Amendments, Corrections and Delayed Entries in Medical Documentation - CMS IOM, Publication 100-08, Chapter 3, Section 3.3.2.5A Reasonable and Necessary Services CMS IOM Publication 100-08, Chapter 3, Section 3.6.2.2. Fact Sheet on Chronic Care Management (CCM) Services Medicare Learning Network (MLN) ICN 909188, May 2015 WPS GHA Resources Local Coverage Determinations (LCDs) for: Psychiatry and Psychology Services (L34616) Drug Testing (L34645) Additional WPS GHA Portal resources: CERT Articles CERT Error Analysis Evaluation & Management Services Page 4 of 5
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