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?

Swiftaudit Security

Swiftaudit’s Team is aware of the disclosed vulnerability affecting Apache Log4j2. Further details are available at CVE-2021-44228 and in Apache’s Log4j2 Security Vulnerabilities page.

Swiftaudit has seen no indication that this vulnerability has impacted our platform’s security. Our primary development platform is .Net in a Microsoft Azure service, therefore this particular Java-based vulnerability doesn’t pose a significant risk. Additional information is available at Microsoft’s Response to CVE-2021-44228 Apache Log4j 2 page.

We are monitoring the issue and will stay vigilant. Swiftaudit is committed to the security of your data. We will post updates as information becomes available.

2022 ICD-10-CM Guidelines By Chapter

The official 2022 ICD-10-CM Guidelines are now available and active! This updated code set is to be used for discharges and patient encounters occurring from October 1, 2021 through September 30, 2022. It’s time to get familiar with what’s new and what has changed.

To help provide a quick reference, we have split the original 115 page document into separate Chapters, each approximately 2-5 pages long and with a focus on specific code groups. By referencing our Chapter list you can more efficiently focus on the specialty you are coding, auditing or teaching.

Be sure to review Section 1.B. General Coding Guidelines for the latest ICD-10-CM general coding guidance.

See what has changed for ICD-10-CM in 2022 in the Tabular Addenda (42 pages).

FY 2022 ICD-10-CM Guidelines (as of July 2022)

Section 1.A: Code Conventions

Section 1.B: General Coding Guidelines

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9

Chapter 2: Neoplasms (C00-D49)

Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) — Reserved for future guideline expansion

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

Chapter 6: Diseases of the Nervous System (G00-G99)

Chapter 7: Diseases of the Eye and Adnexa (H00-H59)

Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) — Reserved for future guideline expansion

Chapter 9: Diseases of the Circulatory System (I00-I99)

Chapter 10: Diseases of the Respiratory System (J00-J99), U07.0

Chapter 11: Diseases of the Digestive System (K00-K95) — Reserved for future guideline expansion

Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)

Chapter 14: Diseases of Genitourinary System (N00-N99)

Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)

Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)

Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

Chapter 20: External Causes of Morbidity (V00-Y99)

Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

Chapter 22: Codes for Special Purposes (U00-U85)

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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.

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 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?