Medicare Compliance & Reimbursement

Improper payments for ESRD on auditors’ radar.

The Centers for Medicare & Medicaid Services (CMS) recently published some results of government auditors’ findings in its April 2015 Medicare Quarterly Provider Compliance Newsletter. From routine errors like the physician forgetting to sign the order to lack of face-to-face documentation, the audit contractors found many issues with claims submitted for end-stage renal disease (ESRD) services.

Insufficient Documentation Among Biggest Errors

The Medicare auditors performed a “special study” of the 90960-90961 series, which relate to ESRD services for patients 20 years of age or older who see their practitioners for face-to-face visits several times per month. “Approximately one-third of the payments for ESRD-related services were improper payments,” CMS said in the report. “The majority of the improper payments were due to insufficient documentation. The rest of the improper payments were due to incorrect coding or no documentation submitted.”

For example, the ESRD provider may have forgotten to sign the order, or the practitioner may have failed to document the face-to-face encounter, leaving auditors unsure of what was actually performed on the date of service.

One procedure note that the auditors reviewed involved a nephrologist who reported 90960 for monthly ESRD services. However, the documentation only included treatment notes signed by the dialysis nurse, with no clinical documentation supporting face-to-face physician visits during the period. If you can’t prove that the doctor saw the patient face-to-face in this scenario, you can only bill the dialysis and not the monthly ESRD service.

TAVR Claims in Question

When it came to transcatheter aortic valve replacement and implantation (TAVR and TAVI) claims, auditors found that one-third of the Medicare payments for services coded with 33361-33362 and 33365 were paid improperly.

Most of the errors were related to insufficient documentation, which means the records were missing proof of the pre-operative evaluation, operative notes, physician’s signature or an attestation for an illegible signature.

The auditors also saw incorrect coding errors in the TAVR and TAVI charts. For example, one physician reported 33361 (TAVR/TAVI with prosthetic valve; percutaneous femoral artery approach) but the documentation revealed that the surgery was performed using a transapical approach through a left thoracotomy. In actuality, this procedure should be billed using 0318T (Implantation of catheter-delivered prosthetic aortic heart valve, open thoracic approach [transapical, other than transaortic]) instead of 33361.

Resource: To read the March 2015 Medicare Quarterly Provider Compliance Newsletter, visit http://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909208.pdf.