Neurosurgery Coding Alert

Don't make these grave medical necessity errors.

There are certain steps you can take when it comes to protecting your neurosurgery reimbursement. Learning which common medical coding errors the Comprehensive Error Rate Testing program (CERT) has identified will go a long way to helping you avoid these same mistakes in your own neurosurgery practice.

Read on to learn more about the CERT program and what you should do when you receive a CERT request.

Side-Step Common CERT Neurosurgery Errors

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

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

Example: To avoid these medical necessity mistakes in your neurosurgery 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 neurosurgeon 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 A mixture lidocaine and cortisone was injected into the affected lumbar joint, after which the needle was withdrawn and hemostasis was achieved.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 neurosurgeon 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 Depomedrol and Marcaine .25%."

How Does CERT Work? Find Out

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."

When CERT Comes Knocking, Make Sure to Answer

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.

Know Your Appeal Rights

As mentioned previously, you do have appeal rights when it comes to CERT. The MAC Novitas does a good job of identifying how this appeals process works.

The first level of appeal is called a "redetermination." You must submit your redetermination request in writing and file it within 120 days from the date on your RA (Remittance Advice) or MSN (Medicare Summary Notice).

You must include all of the following information with your appeal request, according to Novitas:

• The patient's name
• The patient's Medicare Beneficiary ID
• The CERT identification (CID) number
• The date CERT made its initial determination
• The service or items you're requesting the redetermination for
• The date of service
• Both the printed name and signature of the person making the request.
• The printed name and signature of the person making the request
• An explanation of the requestor's relationship to the providing physician.

When you submit a redetermination request, you must also include any information that supports the coverage of the appealed service. And if the denial happened because you did not respond to an Additional Documentation Request (ADR) in time, then you must also include the information requested in the ADR, along with your appeal request.

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