When Medicare delves into claims errors, one stands out above the rest: insufficient documentation.
The Centers for Medicare & Medicaid Services (CMS) audits Medicare Part B claims monthly to identify which ones payers, like Novitas Solutions in Texas, processed incorrectly — usually by overpaying.
For 2019, CMS reported two-fifths of the incorrect payments involved insufficient documentation. In other words, instead of paying some claims, the payers first should have denied them and asked for additional documentation. This might be a missing required element such as a physician signature on an order; support for medical necessity; or documentation showing a service actually was provided, at the level billed.
Novitas and the payers use information from the audits to adjust their claims processing systems to flag claims with insufficient documentation and deny them.
These audits fall under CMS’ Comprehensive Error Rate Testing (CERT) program, which also gathers data to help pinpoint areas of incorrect billing by specialty or code. For example, the CERT review contractor studied claims for arthroscopic rotator cuff repair procedures billed with Healthcare Common Procedure Coding System (HCPCS) code 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair) submitted January through March 2016.
Not surprisingly, insufficient documentation was behind most of the improper payments the reviewer found. Here is a specific example from this study, as described in a recent issue of the Medicare Quarterly Compliance Newsletter (Volume 8, Issue 1):
An orthopedic surgeon billed for HCPCS code 29827 and submitted the following:
- Signed operative report, and
- Signed preoperative history and physical for medical clearance prior to surgery.
Missing from the records was signed clinical documentation to support medical necessity for the billed procedure. CMS said examples of documentation to support medical necessity are:
- Failed conservative treatments prior to the procedure,
- Signed and dated diagnostic imaging reports, or
- Preoperative surgeon notes.
In this case, the surgeon apparently ignored a CERT request for additional documentation, so the CERT review contractor scored this claim as an insufficient documentation error, and the Medicare payer for that surgeon’s geographical area recouped the incorrect payment.
TMA’s reimbursement specialists recommend the Medicare Quarterly Compliance Newsletter as a good source for learning about findings — so you can avoid billing errors — from the CERT program and audits by Medicare payers and contractors like Recovery Audits. Subscribe online to this newsletter and other CMS email updates. Also, visit the TMA Medicare webpage for news and information.
Remember, if you have questions about billing and coding or payer policies, TMA’s reimbursement specialists can help. Email questions to paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955. Also, consider calling on TMA Practice Consultants for an in-depth review of your documentation and claims coding that could identify deficiencies and areas of risk for an audit.
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