Medicare Will Be Looking for These Documentation Deficiencies

The errors Medicare's Comprehensive Error Rate Testing (CERT) program finds today in already-paid claims become fodder for tighter claims processing  and maybe prepayment audits in the future. Paying attention to CERT findings is one way to avoid denied Medicare claims down the road.

CERT randomly audits claims monthly to determine if Medicare contractors, such as Novitas Solutions, paid the claims correctly. In most of the improperly paid claims for second quarter 2014, contactors paid the claims despite insufficient documentation on the part of the physician. You can find details and examples of the three categories below in the Medicare Quarterly Provider Compliance Newsletter, Volume 4, Issue 4 (PDF).

Bariatric surgery  About 98 percent of claims audited lacked some documentation. For example:

  • No physician's signature on the procedure note;
  • No signature log or attestation submitted;
  • Missing documentation on BMI greater than 35;
  • Missing documentation of at least one comorbidity;
  • Missing documentation of prior failure for medical treatment of obesity; and/or
  • Documentation that did not meet the requirements of the national coverage determination, local coverage determinations (LCDs), and/or Centers for Medicare & Medicaid Services (CMS) articles.

To avoid some of these errors, see the Novitas Solutions LCD: Bariatric Surgical Management of Morbid Obesity (L32619); see also this hyperlinked list of CMS articles about Medicare's signature requirements in a variety of situations (PDF).

Kyphoplasty and vertebroplasty — Insufficient documentation caused about 97 percent of the improper payments. For example: 

  • No physician's signature on the procedure note,
  • No documentation of the patient's clinical condition,
  • No documentation of the response to conservative care, and
  • No documentation that met the requirements of the local coverage determination.

See the Novitas LCD: Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous (L32685)

Obesity counseling  Improper payments resulted from lacking documentation in about 92 percent of claims audited. For example:

  • No physician's signature on the procedure note,
  • No documentation of the patient's clinical condition,
  • No documentation that the beneficiary has a BMI greater than or equal to 30kg/m2,
  • No documentation that after six months the beneficiary lost 6.6 pounds or 3kg, and/or
  • No documentation that obesity counseling and dietary assessment occurred. 

See the CMS article, "Intensive Behavior Therapy (IBT) for Obesity," MLN Matters No. MM7641 Revised (PDF).

More About CERT: What You Have to Do

Contractors like Novitas use CERT audit information to find the cause of their payment errors and work to resolve them. Although CERT is not a fraud hunt but a "self-check" of the Medicare payment system, you still need to respond in a timely manner to a request for medical records, or you'll have to refund the Medicare payment you received for the relevant claim(s).

A medical records request from the CERT review contractor AdvanceMed alerts you that one of your claims has been selected as part of the monthly random sample. You'll receive a letter requesting the medical documentation. No response or sending in only part of the requested documentation will result in a CERT denial of your already-paid claim.

The records request will come with a barcoded cover sheet identifying the beneficiary and date of service. You must include the barcoded coversheet in front of documentation you provide, regardless of the media you use. Place it in front of each record when submitting multiple records, and use it when responding to a request for additional documentation. (Do not use a barcoded coversheet from a previous request.)

 Here is your response timeline:

  • Day 0: First contact via fax or email; you have 45 days to respond.
  • Day 30: Second contact via fax or mail (reminder letter); you have 15 days left to complete the request.
  • Day 45: Third contact via fax or mail grants a 15-day extension.
  • Day 60: Fourth contact via mail grants a second 15-day extension prior to claim denial/payment recovery.
  • Day 76: CERT denies the claim under the assumption that you can't provide the documentation because you didn't provide the service.

Additional helpful information about responding to a CERT request is on the Novitas CERT page. Also, the CERT Provider Website provides links to helpful documents such as the Disaster Attestation Letter and an example of a Signature Attestation Letter. You also can manage your contact information for the CERT contractor there.

If you care to delve into CERT data, you can view datasets of reviewed claims for 2011, 2012, and 2013. The CMS website also provides information CERT program and links to CERT reports.

Published July 22, 2014

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