CERT Audits Identify Top Coding Errors

In a recent Comprehensive Error Rate Testing (CERT) audit review of Part B claims with entry dates May 1, 2002, through May 31, 2010, the top three error categories included insufficient documentation, medically unnecessary service or treatment, and service incorrectly coded. Other errors, such as unbundling, were negligible. These general categories of errors recently reported by the CERT contractor for jurisdiction 4 (Colorado, New Mexico, Oklahoma, and Texas) aren’t all that surprising. What is surprising are the more specific error types that fall under the main categories.

Insufficient Documentation

The most common error made by providers was insufficient documentation (41 percent); and it’s not what you might think. Generally when a claim is rejected due to insufficient documentation, one might think that the physician failed to document the procedure sufficiently. On the contrary, 25 percent of the insufficient documentation errors identified in the CERT audit review were simply because the documentation did not include the service date, the patient’s name, or a legible provider identifier.

Evaluation and Management – CEMC

Tip: The medical record should be complete and legible, utilizing widely accepted and recognized abbreviations and symbols. It should also be dated and authenticated by the physician.

Sadly, 13 percent of claims failed simply because signature requirements were not met. Medicare requires the record to contain a provider signature or legible identifier for every service reported to Medicare for payment. This includes services provided, services ordered, and teaching physician services.

The physician’s signature can be either handwritten or electronic, but stamped signatures (i.e., rubber stamps) are not acceptable. If the provider’s signature is not legible, a signature log must be included with the medical documentation submitted. If the signature is altogether absent from the medical record, an attestation statement must be included confirming the provider performed the services reported to Medicare for payment.

Only about 11 percent of the CERT identified errors were due to documentation failing to adequately describe the service defined by the CPT®/HCPCS  Level II code or modifier.

Other insufficient documentation errors by subcategory include (percentages are rounded up):

  • Incomplete hospital record (13 percent)
  • No signature (6 percent)
  • Incomplete or missing valid plan of care (including physician signature and date) (6 percent)
  • Records for wrong DOS were submitted (5 percent)
  • Incomplete physical, occupational or speech therapy records (4 percent)
  • Missing results for diagnostic or laboratory test (3 percent)
  • Though a valid ICD-9-CM code(s) was submitted, the ICD-9-CM code(s) alone was insufficient information (.50 percent)

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

For diagnostic tests to be deemed medically reasonable and necessary, a practitioner who is treating the patient must order the test. The medical record must contain evidence of the practitioner’s intent for the test(s) to be performed (or contain an explicit order). The  practitioner’s legible signature must be included on the medical record.

Tip: To pass the medical necessity test, always include documentation showing the practitioner’s intent or a legibly signed order for the diagnostic or laboratory test(s).

Incorrectly Coded Services

Most of the incorrect coding errors reported by the CERT contractor were related to evaluation and management (E/M) services.

Services incorrectly coded by subcategory most often included:

  • E/M does not meet level required (66 percent)
  • Services incorrectly coded (16 percent)
  • Documentation is illegible and service was denied or down-coded (10 percent)
  • Exam component does not meet the level required (4 percent)
  • History component does not meet the level required (2 percent)
  • Service does not meet the definition of a new patient (1 percent)
  • Service does not meet the definition of critical care (1 percent)

Tip: Documentation should support the intensity of the evaluation and/or treatment, including thought processes and the complexity of medical decision-making.

TrailBlazer Health Enterprises, Medicare administrative contractor (MAC) for jurisdiction 4, suggests three steps to decrease error rates:

  1. Understand Medicare’s requirements.
  2. Understand the reasons for the errors.
  3. Take action to decrease errors.

Most of the errors identified by the CERT contractor could have been avoided by simply requiring physicians and staff to ensure each record answers who, what (and how many), where, when, and why, TrailBlazer advises. Further, make sure all requested medical records are submitted and do not hesitate to include additional records to show the service was medically reasonable and necessary.

Source: TrailBlazer Health Enterprises


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