Neurology & Pain Management Coding Alert

Errors often emerge when treating back, neck issues in patients.

Coders concerned with protecting the practice’s bottom line should draw a bead on the common medical coding errors identified by the Comprehensive Error Rate Testing program (CERT).

Why? You need to know CERT because it will help you identify and avoid the same coding mistakes that have cost other practices reimbursement, reputation — or both.

Start with this primer about the CERT program, so you’ll know what to do when you receive a CERT request.

Mark These Common CERT Errors

Some of the top mistakes CERT has identified for procedures are due to medical necessity errors. These procedures include the following:

• Degenerative nervous system disorders
• Intracranial hemorrhage/cerebral infarction
• Back and neck procedures, except spinal fusion.

Example: To avoid these medical necessity mistakes in your practice, take a look at this example: You report 64493 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level) for a facet joint injection to one lumbar level.

The physician documents the following: The patient was prepped and draped in a sterile fashion. The needle was inserted through the skin, after which it was advanced into a lumbar facet space using fluoroscopic guidance. A mixture of lidocaine and cortisone was injected into the affected lumbar joint, after which the needle was withdrawn and hemostasis was achieved.

Problem: This operative note does not establish medical necessity for the procedure you reported. According to »»» the facet joint injections, medial branch blocks, and facet joint radiofrequency neurotomy policy for the Medicare Administrative Contractor (MAC) Noridian, “A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre and post-procedural pain assessments.”

Solution: The physician should have described which anatomic area he injected. In the example note, it only refers to “the lumbar facet space” rather than the specific area. So, he should have documented the needle he used and the medication he injected.

For instance, “The L45facet joint was identified under fluoroscopic guidance. Using a 22-gauge spinal needle, 3.25 inches were advanced into the facet joint and the nerve was injected with 40mg Depo-Medrol and Marcaine .25%.”

Read on to See How CERT Works

During each reporting period, CERT chooses a stratified random sample of claims submitted to A/B Medicare administrative contractors (MACs) and durable medical equipment MACs (DMACs) and requests that the provider and or the suppliers who submitted those claims provides the supporting medical documentation.

Then, an independent medical review contractor reviews these claims to see if they were correctly paid per Medicare coverage, coding, and billing requirements.The current medical review contractor is AdvanceMed, and the current statistical contractor is The Lewin Group, Inc.

Upon review, if AdvanceMed discovers that criteria was not met in those claims or if the provider didn’t submit the proper medical documentation to sufficiently support the billed claim, the claim is identified as either a total or partial improper payment. The improper payment may be recouped for overpayments or reimbursed for underpayments, CMS says.

CMS calculates the results of this review, and this becomes the national, annual Medicare Fee-for-Service (FFS) improper payment rate. The Department of Health and Human Services (HHS) publishes these results in its agency financial report (AFR).

Why should this matter to you? This improper payment rate calculation is important because it measures the MACs performance and gives CMS insight into what caused the claim submission errors, according to a CMS fact sheet about Medicare claim review programs.

Don’t miss: “The improper payment rate is not a ‘fraud rate,’ but is a measurement of payments that did not meet Medicare requirements,” CMS says on its website. “The CERT program cannot label a claim fraudulent.”

If CERT Calls, Pick It Up

You can respond to a CERT request in several ways, according to Michael Hanna, MPA, CDME, provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar:

• Fax — this is the preferred method, Hanna said. “Always include the barcode sheet as part of your » fax package. This simply marries the documentation you’re submitting with that particular date of service the CERT contractor has chosen for a review.”
• The electronic submission of medical documentation system (esMD). With this method, you use the gateway you contracted with and follow standard procedure.
• Mail — “If it’s a sizeable amount of documentation, or you’ve already saved it to a CD, you can mail it in,” Hanna added.

Don’t miss: You can make extension requests by telephone only.

Caution: Normally, the CERT contractor only grants extensions in extreme circumstances such as natural disasters like hurricanes, tornadoes, and ongoing fires, according to Hanna.

“But, if you are simply waiting on medical records from the physician, it is possible the CERT contractor may not grant that extension,” Hanna said. “If that is the case, you should always send the CERT contractor what you have available, and then if they disagree or find something missing or not valid, you do have appeal rights.”

Any claim errors the CERT contractor finds will result in a revised Medicare admittance advice where they will deny that claim and an overpayment demand where they ask you to recoup the money, Hanna cautioned.

Resource: To learn more about the CERT program, visit http://www.cms.hhs.gov/CERT/.