CMS CERT FINDINGS: Insufficient Documentation Errors Leading Cause of Overpayments

A recent update from the American Institute of Healthcare Compliance (AIHC) reminds us that CMS has a MedLearn (MLN) Fact Sheet titled “Complying With Medical Record Documentation Requirements.”

THE PROCESS

The MLN Fact Sheet describes CMS due diligence program called CERT.

The CMS CERT Program measures improper payments in the Medicare FFS Program.
The CERT Program is managed by two contractors, the CERT Statistical Contractor (CERT SC) and the CERT Review Contractor (CERT RC). The Statistical Contractor determines how claims will be sampled and calculates the improper payment. The Review Contractor requests medical records from providers and suppliers who billed Medicare. The Review Contractor reviews the selected claims and associated medical records for compliance with Medicare coverage, coding, and billing rules.

THE ERROR FINDINGS

The MLN Fact Sheet lists common procedures often found with insufficient documentation by the CMS CERT Program. These common procedures and findings include:

Vertebral Augmentation Procedures (VAPs)
● Missing signature and date
● No evidentiary radiographs performed to support medical necessity
● Insufficient medical record documenting that the provider tried conservative medical management but it failed or was contraindicated
● No signed and dated attestation statement for the operative report if a physician signature was missing or illegible; if the operative report is electronically signed, the protocol should also be submitted

Physical Therapy (PT) Services
● Documentation did not support certification of the plan of care for physical therapy services.
● The physician’s/NPP’s signature and date of certification of the plan of care or progress note indicating the physician/NPP reviewed and approved the plan of care is required.

Evaluation and Management (E/M) Services
● Office Visits Established, Hospital Initial, and Hospital Subsequent were identified as the top three CERT errors in E/M service categories
● High errors rates of insufficient documentation, no documentation, and incorrect coding which supported the medical necessity and accurate billing of the E/M services

Durable Medical Equipment (DME)
● Certain DME HCPCS codes (such as, hospital beds, glucose monitors, and manual wheelchairs) require a valid detailed written order prior to delivery
● The physician’s NPI must be on the valid detailed written order
● Medicare will pay claims only for DME if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service
● As a condition for payment, a physician, PA, NP, or CNS must document a face-to-face examination with a beneficiary in the 6 months prior to the written order for certain items of DME

Computed Tomography (CT) Scans
● Documentation of the plan or intent to order a CT scan was insufficient to support medical necessity.
● If the handwritten signature is illegible, include a signature log, and if electronic, the protocol should also be submitted.

THE FINANCIAL IMPACT

CMS CERT Program reports $25.03 billion in improper payments in 2021.

Do you know your organization’s exposure to documentation errors?

Is CMS / HHS really checking for undercoding?

Yes. They are!

The 2018 Medicare Fee-for-Service Supplemental Improper Payment Data identifies undercoding in their audit findings.

CMS reported 1.93 billion dollars in underpayments in 2018.

1.93 billion dollars equates to about $4,800 per active MD in the United States per year who typically bill E/M codes. There are 620,520 active MD’s per the AMA Physician Masterfile (December 2019). 36% are in specialties as anesthesiology, pathology, psychiatry, and radiology using other CPT^(R)/ HCPCS codes.

CMS reported that Office Visit E/M codes 99213, 99212, Initial Hospital E/M code 99222, and Emergency services E/M code 99283 are among the top 8 codes being reported as undercoded / underpaid.

Click to access 2018MedicareFFSSuplementalImproperPaymentData.pdf

What about commercial payers?

You can google to see the number of lawsuits and filings against commercial payers for underpayment. The American Bar Association has a “healthy” pool of newsletters focused on health law and payment disputes. Many of these disputes against commercial payers are about underpayment, not overpayment.

Many RCM consultants will tell you that it’s good business policy to track payments from your payers. If your underpayments from your commercial payers is significant, having a base of proper coding can strengthen your case for dispute and/or negotiations. Your coding pattern is collected and trended by all of your payers – whether Medicare or commercial payers. They know your coding pattern, do you?

What is your percentage of undercoding?

What is the impact of undercoding on your practice’s revenue?

Are you describing your practice’s risk burden properly, so you can best serve your patients?

Internal Audits-Undercoding is a good strategy, right ?

Overcoding is an obvious audit finding. Most internal and external audits are focused on overcoding as a high risk topic. The risks are typically listed as submitting a “False Claim,” potentially being flagged as an audit candidate, being charged for overpayments, and being an “outlier.”

Due to these often touted compliance concerns, many practices choose a strategy of undercoding.

Is undercoding a good strategy to stay  “under the radar”?

Noviatas, a CMS Medicare contractor responsible for providers in AR, CO, DC, DE, MD, LA, MS, NJ, NM, OK, PA, TX, Indian Health & Veteran Affairs sees undercoding as “aberrant.”

CERT is a measure of improper payments. The goal of CMS and Novitas is to pay claims that meet Medicare’s requirements and pay them at the proper level of service. When there is an underpayment due to under coding, we did not pay the claim correctly and it is counted as an improper payment error. You are reimbursed for the higher level of service. Under coding misrepresents the true level of care provided to Medicare beneficiaries.

Under coding errors can statistically impact calculated error rates in the tens of millions of dollars. These statistics are used to calculate future Medicare payments and track trends in healthcare delivery. Patterns of under coding may be viewed as aberrant and open your practice up to audits and reviews. In addition, under coding impacts your practice revenue. You are not being appropriately paid for the level of service you provide to your patients. Correcting under coded claims can mean costly appeals.

Auditors at Healthcare Compliance Network (HCN) an healthcare compliance and RCM firm provides this perspective.

The Dangers of Undercoding

… the golden rule of coding is, and always will be, to code to the highest specificity. The payers don’t want you to lowball – they want the most accurate code which reflects the service performed. Without that, they cannot effectively rate policies, understand the risk burden, accurately set premiums, etc.

An undercoding error is still an error, and it will be graded as such in the event of an audit. That’s important because an unacceptable error rate will keep you on the radar, even if it’s due to undercoding.

Plus, it’s worth reiterating the adage that too much of anything is bad. Audits are often triggered by aberrant billing distribution patterns by CPT code. If you submit an abnormal number of claims with lower-level codes it is, in effect, no better than generating an abnormal volume of high-level codes. It implies that something is not right because you are outside the norm.

What is your percentage of undercoding?

What is the impact of undercoding on your practice’s revenue?

Are you describing your practice’s risk burden properly, so you can best serve your patients?

Internal Audits – Financial Impact

In our last post, we reviewed the importance of an internal audit plan. Now let’s look at how that might impact your financials.

Evaluation and Management (E/M) services have been a high priority audit topic for all payers for a long time. In 1995, we released E&M Coder as an audit and education tool. In 2010, E/M services accounted for almost 30% of all Part B payments, equating to $32.3 billion. [We can give at least $100 to everyone in the USA every year for E/M services paid just by Medicare.]

In a study by the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) in 2010, they found $6.7 billion of inappropriately paid claims, representing 21% paid for E/M services that year.

Of the total $32.3 billion paid for E/M services in 2010, 42% of claims were incorrectly coded. They were either higher (upcoded) or lower (downcoded) than they should have been. 19% of claims had insufficient documentation for the E/M services billed.

Though this Study is over 10 years old, what if

• 42% of your billing was improperly coded?
  • 21% over coded – what is your risk?
  • 21% under coded – what revenue opportunity was lost?

What if

• 20% of your billing was improperly coded?
  • 10% over coded – what is your risk?
  • 10% under coded – what revenue opportunity was lost?

How much would these error rates cost your practice?

In the December 2020 MGMA Survey, those who reported their denials were due to documentation / coding issues noted the following as the top reason for their denials:

https://www.mgma.com/data/data-stories/finding-hidden-treasure-by-uncovering-and-fixing

Coding issues (including wrong modifier and improper bundling of CPT® codes) — 23%

Medical necessity requirements — 14%

Missing information/documentation — 11%

Do you know what your top reasons for denials or underpayment are?

How confident are you with your provider’s 2021 E/M coding?

If you use internal staff to code and/or audit, when was the last time you had an external review done?

Image credit: graphicstock

Internal Audits

Why is an internal audit plan essential for healthcare practices?

An article by the AMA “13 reasons your practice should have a medical record audit” quotes Deborah J. Grider as saying that an audit “is a preventive measure if done at least once a year.”

What does an audit prevent?

One key risk is governmental investigational auditors.

On CMS’ Recovery Audit Program webpage, it states: “CMS often receives referrals of potential improper payments from the MACs, UPICs, and Federal investigative agencies (e.g., OIG, DOJ).”

As a sample, here are the Approved Recovery Audit Topics required of all Medicare health care insurers (MAC) related to evaluation and management services.

In the 2018 AMA article Avoid these missteps to slash your medical coding audit risk, the author writes:

The OIG also warns against billing for services:

• You did not actually render.
• Were not medically necessary.
• Were performed by an improperly supervised or unqualified employee.
• Were performed by an employee who has been excluded from participation in the federal health care programs.
• That were of such low quality that they are virtually worthless.
• That were already included in the global fee, such as billing for an E/M service the day after surgery.

What about private insurers?

As of 2019, Blue Cross states: “Blue Cross follows the Centers for Medicare & Medicaid Services (CMS) 1995/1997 and CPT E/M selection guides for these services.” Most private insurers follow the policies and guidelines published by CMS and the AMA.

An internal audit plan is essential to ensure that your practice stays healthy.

There are many firms that offer compliance services. Compliance is often the topic of conferences, webinars, in-services, and articles. As a result, many practices have a compliance plan.

The operational questions are:

When was the last time you reviewed your compliance plan?

What topics in the compliance plan are not being followed?