Medicare Compliance & Reimbursement

Tip: Sign your medical orders to avoid CMS scrutiny.

A new report from Medicare should remind you why it's so important to maintain - and submit - complete supporting documentation for claims.

If you repeatedly send CMS paperwork that lacks provider signatures, the medical orders are considered incomplete. The agency reminds practices that without thorough signed physician notes that fully detail the necessity for arthroscopic rotator cuff repair, the claim is invalid - and your Medicare pay is revoked.

According to the October 2017 Medicare Quarterly Provider Compliance Newsletter, CMS's CERT contractors are reporting that they have seen this issue multiple times. In some cases, the physician ignores the request for supporting documentation and returns the original documentation unchanged.

For Example: "An orthopedic surgeon billed for HCPCS code 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair)," said CMS in its Medicare Quarterly Provider Compliance Newsletter out last month. The medical documentation included:

• "Signed operative report which documented left rotator cuff repair, repair ofSuperior Labral tear from Anterior to Posterior (SLAP) lesion, and biceps tenotomy;
• Unsigned orthopedic surgeon's note which documented a fall injury with pain in the rotator cuff distribution and weakness in the arm, with tenderness and pain over the distal aspect of the biceps;
• Unsigned orthopedic surgeon's note which documented left shoulder rotator cuff tear via Magnetic Resonance Imaging (MRI) with persistent weakness and failed conservative care measures; [and]
• Two unsigned orthopedic surgeon's post-operative follow-up visit notes."

However, despite requests for updated information to verify the medical necessity of the procedure, the provider continued to submit the original, insufficient documentation, the report suggested. Eventually, "the CERT review contractor scored this claim as an insufficient documentation error and the MAC recovered the payment from the provider," the release noted.

Look at the Reasoning

When CMS finds high error rates, Medicare Administrative Contractors (MACs) will request recoupment from the practices overpaid in error like they did for those claims highlighted in the CERT review. "If the insurer became aware that a practice coded incorrectly or maintained insufficient documentation to support their claims, that will lead them to recoup reimbursement from the practices that billed improperly, since the practices didn't meet the criteria to have earned that reimbursement," says healthcare consultant Terri Orcala of Orcala Billing in Kansas City, Mo.

Warning: If a certain type of claim - like those coded using HCPCS code 29827 - keeps getting returned, CMS enlists its investigative resources (MACs, CERT review contractors, Recovery Audit Contractors [RACs] and eventually the Office of Inspector General [OIG]) tocall out outliers and eradicate the issues. So when yousee a particular code or service being reviewed again and again on the CERT review, under the RACs' issues, or on the OIG Work Plan's list of monthly topics, it means your practice may want to revisit those claims andstudy the CMS guidance to avoid denials, audits, andpaybacks.

"For a provider facing an audit, responding to the audit findings sometimes will involve a maze of statutes, regulations, manual provisions, and other written guidance," advises attorney Michael D. Bossenbroek, Esq. of Wachler & Associates, P.C. in Royal Oak, Michigan, "Properly understanding these standards may give the provider appropriate technical defenses in the audit."

Remember: Medicare Fee-For-Service (FFS) Improper Payment Reports come out annually, are compiled by the Comprehensive Error Rate Testing (CERT) program, and offer providers the details about the year's biggest FFS claims issues. But the quarterly CERT updates hone in on specific issues that MACs see repeatedly in error over a shorter period of time.

CMS Looks at Hospital Outpatient Services with a Magnifying Glass

CERT review contractors also focused heavily on outpatient services' claims ranging from medication administration and lab testing to outpatient surgery and therapy, uncovering a vexing issue related to insufficient documentation that added $3.1 billion to the improper payment rate last year. The top two reasons that led to the quarterly spotlight concerned medical orders that lacked any kind of medical necessity, particularly for labs and diagnostic testing, and incomplete notes, the Medicare Quarterly Provider Compliance Newsletter explained.

Scenario: In one review, "a provider billed an APC payment line for HCPCS code G0463 (Hospital outpatient clinic visit for assessment and management of patient) with APC code 00634 (Hospital Clinic Visits)," the release noted. However, "the service of HCPCS code 85610 (Prothrombin time) was a packaged service under APC code 00634." The claims notes submitted only included "prothrombin time results for the date of service" and a "signed pharmacist progress note," which were clearly insufficient to define the necessity of the service.

Though requests were made by CMS to the provider, ordering and billing documentation were never updated, completed, or sent following both the MAC and federal solicitations, the release suggested. And as a result of the failed follow-up, the billing provider was forced to return payment to the MAC.

Consider This Federal Guidance on Signatures

Medicare requires either handwritten or electronic signatures during its medical claims review process for a submitted claim to be correct; however, "stamped signatures are not acceptable," according to the Medicare Program Integrity Manual, Chapter 3, Section 3.2.4. But remember there are always exceptions in Medicare. Look at the following signature exceptions mentioned in the guidance that MACs, CERT reviewers, ZPICs, and SMRCs allow:

1. Faxed copies of the original signature for hospice certification.
2. Some clinical diagnostics tests, but the "progress notes" outlined by the treating physician and documentation showing "intent" must have a signature.
3. NCDs, LCDs, and other CMS regulations and instructions "for conditions of payment related to signatures (such as timeliness standards for particular benefits) take precedence."
4. A rubber-stamped signature is allowed for those with a proven disability under the Rehabilitation Act of 1973, and/or who are incapable of physically signing.

Find the Medicare Program Integrity Manual, Chapter 3 at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf.

Important: "If the signature is missing from an order, MACs, SMRC, and CERT shall disregard the order during the review of the claim (e.g., the reviewer will proceed as if the order was not received)," instructs CMS. Because of this important requirement, providers and their staffs should take the time to review notes thefirst time around, ensuring that the physician's signature is there and legible. But mistakes are made, so if you are audited, consider looking at your authentication processes and update them, the guidanceadvises.

Endnote: With increased compliance scrutiny by the MACs with the Targeted Probe and Educate program, a monthly OIG Work Plan with target areas, and increased pressure to get your claims right the first time, practice coding compliance plans are essential to ensure you get the pay you deserve.

Resources: To review the October 2017 edition of the Medicare Quarterly Provider Compliance Newsletter, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909271.pdf.