Email not displaying correctly? View it in your browser. Issue #5 — Nov 24, 2010
AAPC BillingInsider eNewsletter

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F R O M   T H E   F I E L D

CERT Audit Identifies Top Billing Errors

You may or may not be surprised by what Trailblazer's Comprehensive Error Rate Testing (CERT) audit in Colo., N.M., Okla., and Texas found to be the top Part B billing errors.

Insufficient Documentation

Insufficient documentation errors because the documentation did not include the date of service, the patient's name, or a legible provider identifier are the most noteworthy.

Some claims fail simply because signature requirements are not met. Medicare requires records contain a signature or legible identifier for every service reported. Your physician's signature can be either handwritten or electronic, but stamped signatures (eg, rubber stamps) are not acceptable. Include a signature log if the signature isn't legible and an attestation statement if there is no signature at all. Other errors include:

  • Incomplete hospital record (13 percent)
  • Incomplete or missing plan of care
  • Records for wrong date of service
  • Incomplete physical, occupational, or speech therapy records
  • Missing results for diagnostic or laboratory test
  • The valid ICD-9-CM code submitted was insufficient

Medically Unnecessary Services

For Medicare to determine a service to be medically reasonable and necessary, that service must be:

  • Safe and effective
  • Not experimental or investigational
  • Appropriate in duration and frequency
  • Performed in accordance with accepted standards of medical practice
  • Furnished in an appropriate setting
  • Ordered and furnished by appropriate personnel
  • Meeting but not exceeding the patient’s medical need

To be paid for diagnostic tests, the physician must order the test with the documentation providing evidence of intent for the tests to be performed. In other words, make sure the physician signs the documentation.

Incorrectly Coded Services

Not surprisingly, most incorrect coding errors reported by the CERT contractor are related to evaluation and management (E/M) services, including:

  • E/M does not meet level required (66 percent)
  • Services coded incorrectly
  • Illegible documentation service was denied or down-coded
  • Exam component not meeting the level required
  • History component not meeting the level required
  • Service not meeting the definition of a new patient
  • Service not meeting the definition of critical care


F E A T U R E D   S T O R Y

6 Ways to Avoid Denied Claims for Spine Procedures

Mona Kaul, chief coding and compliance officer of GENASCIS, shares the following six ways ambulatory surgery centers (ASCs) can better avoid denied claims on spine procedures, as seen in Becker's ASC Review.

  1. Physicians must document all necessary information. When documenting, physicians should describe the surgical procedure in detail, allowing you to clearly visualize the entirety of the surgical encounter, including the approach used, and if the surgeon operated on more than one level. Physicians should also describe any implants or grafts used, and include details such as the type of implant and number of screws used.
  2. Amend documentation in writing. Ask the physician for clarification. Make sure changes to the chart are in writing and don't accept verbal direction.
  3. Differentiate the spine anatomy. In-depth knowledge of spinal anatomy allows a coder to differentiate between procedures such as laminotomy (hemilaminectomy) and laminectomy (unilateral) and to understand arthrodesis and instrumentation.
  4. Identify primary procedure and multiple procedures. Code the primary procedure first and then include the add-on code for each additional procedure. Do not use modifier 59 for add-on procedures.
  5. Locating spinal procedures in the CPT® codebook. Codes for the nervous system are available in two sections of the CPT® codebook: 22010-22865 and 61000-64999. Select the most appropriate code for the service rendered regardless of what section it is listed in.
  6. Understanding rules for implant billing. Be ready to use HCPCS Level II codes for implants when coding for an arthrodesis, as some payers may require. Be ready to share your implant invoices with the payer.


How Long Does It Take Your Payers to Certify Providers?

A major frustration of billing and practice management is assuring a new or existing provider is credentialed with a payer. Sometimes payers can take months to respond to the application.

AAPC Physician Services is curious. How long do you have to wait for a provider to be credentialed? Do you have regulations in your state preventing applications from languishing in the In Box? Please take a moment to complete our anonymous survey at We'll let you know what the results are.

FROM THE FIELD is thoughts and experiences from you the reader. If you have any tips, ideas, case studies or just anecdotes please submit them to us for future edtions.

In This Issue
CERT Audit
Avoid Denials for
Spine Procedures

Payer Survey

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