Why, What, and Who Keys to Recoupment-Proof Documentation

The Centers for Medicare & Medicaid Services (CMS) has reported on three completed Comprehensive Error Rate Testing (CERT) reviews and their findings. The studies looked at claims for retinal photocoagulation (HCPCS code 67228), facet joint inspection (HCPCS code 64635), and radiation therapy (HCPCS code 77330).

Across the board, improper payments the CERT contractor identified (and recouped for Medicare) resulted from insufficient documentation on the part of the physician — either medical documentation inadequate to support payment for the services billed or missing documentation elements required as a condition of payment. That’s why for any service billed to Medicare, it’s important to review relevant national and local coverage determinations for coding and documentation specifics.

The mere lack of a signature on specific portions of otherwise complete documentation can be enough to warrant a recoupment. Examples of common documentation errors from all three studies are:

  • Inadequately describes the service as defined by the HCPCS code;
  • No documentation to support the medical need for the procedure;
  • No procedure note;
  • No signature log or attestation submitted; and
  • No physician’s signature on a procedure note, diagnostic report, or progress note. 

Among other errors highlighted in the CMS report:

  • For retinal photocoagulation: no intent to order diagnostic or lab test; no diagnostic test result.
  • For facet joint injection: no valid physician order (includes physician signature or date); no preoperative surgeon’s office notes; though a valid ICD-9 code(s) was submitted, the ICD-9 code(s) alone was insufficient information (the CERT study covered dates of service in 2015). Note that Texas Medicare payer Novitas Solutions has a local coverage determination policy for Facet Joint Injections (L34974) and the related Pain Management (L35033).
  • For radiation therapy: no radiation therapy plan was submitted. 

The Medicare Quarterly Provider Compliance Newsletter for January 2017 gives examples of claims reviewed in the CERT studies and why they resulted in recoupments.

Have a coding or documentation question? Email your question to TMA’s reimbursement specialists at paymentadvocacy[at]texmed[dot]org, or call (800) 880-7955. Or contact TMA Practice Consulting to have a certified professional coder conduct a coding and documentation check-up or in-depth review for your practice, or train you and your staff on site. 

Published Feb. 7, 2017

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Last Updated On

February 08, 2017

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