Medicare Compliance & Reimbursement

Can't get your physician to document thoroughly? The latest CERT report results might whip him into shape very quickly.

According to the most recent Comprehensive Error Rate Testing (CERT) results, Medicare requested $9.3 billion in reimbursement back from practices that lacked complete documentation, and your practice may have been one of them.

The new CERT results, which reported data from claims submitted to Medicare between Oct. 1, 2006, and Sept. 30, 2007, were released May 16.

The new report didn't include only bad news, however. Despite an improper-payment tally of $10.2 billion (including both overpayments and nearly $1 billion in underpayments), the error rate dropped to just 3.4 percent, a small fraction of the whopping 14 percent error rate that CMS found in 1996.

CMS counted more than $785 million in errors for practices that were missing documentation, and $1.3 billion in insufficient documentation errors. This number is alarming, but the figure becomes even worse when you hear just what types of errors CMS discovered.

"The fact that the error rate has dropped is great news," says Jay Neal, a consultant in Atlanta. "But an error rate of over $10 billion is still high."

For example: One Medicare carrier paid a practice $324 for a retinal lesion destruction, but when the payer asked the physician for the records, it found that the date of service was missing. After the reviewer requested the records several times, the CERT contractor "counted the entire payment as an error," the report said.

Occupational therapists logged a 21.2 percent error rate, and neurosurgeons weren't far behind with an error rate of 15.3 percent.

One possible reason for the high neurosurgery error rate could be the high number of codes involved in one neurosurgical procedure, says Denae M. Merrill, CPC-E/M, of Merrill Medical Management. "A 'simple' laminectomy with fusion, for example, has an average of seven codes. There is also the issue of bundling, from a CPT and/or Correct Coding Initiative (CCI) perspective, which then needs modifier consideration," she says.

If your favorite code is 99211, watch out. The CERT report reveals that more than 15 percent of claims submitted to Part B for this code last year were missing critical documentation, causing Medicare to request more than $20 million back from providers.

The CERT report found 99211 (Outpatient E/M that may not require a physician) billed inappropriately across the board, both in the "insufficient documentation" and "no documentation" categories.

"Practices may be surprised by this high error rate because many people think it doesn't take comprehensive documentation to report 99211," says Heather Corcoran with CGH Billing. "But that's probably the exact reason it's billed in error so often -- practitioners assume because it's a low-level code, they don't have to document very much information, which is wrong. Thorough documentation is necessary no matter how much money you'll collect for a particular code."

Carriers requested more than $100 million back from practices last year due to insufficient documentation for subsequent hospital care code 99232, which had a 4.1 percent error rate.

Possibility: Physicians who are unsure of which hospital code to report may simply rely on 99232.

"Hospital visits are totally up to the physician or provider to document and report, so whether or not they understand what is required for each level of service is probably not known," says Denise Paige, CPC, of Torrance Orthopaedic and Sports Medicine Group.

"It's a type of coding issue that, documentation-wise, should be reviewed with the physician to help them understand what is required."

Not all of the coding errors revealed in the CERT report were related to upcoding. In fact, the document reveals that Medicare should have paid out an additional $300 million, but practices undercoded claims and didn't collect their due.

The most frequently undercoded claim was 99307 (Subsequent nursing facility care), which had a 17.6 percent error rate. Not far behind was emergency department visit code 99282, followed by 99211.

To read the full CERT results, visit the CMS Web site at http://www.cms.hhs.gov/CERT.