Pathology/Lab Coding Alert

In fact, many specialties suffer a common malady that results in “improper” payments, according to the report, and that’s “insufficient documentation.” Read on for a snapshot of how clinical laboratories and pathology practices fared in the latest CERT report, and use the news to focus on improving your documentation practices in 2020.

Understand How CERT Data Impacts Your Lab

CMS uses the information garnered from the CERT program in three different ways that you need to know.

First, CMS uses providers’ data to “protect the Medicare Trust Fund by identifying errors and assessing error rates, at both the national and regional levels,” according to Part B Medicare Administrative Contractor (MAC) CGS Medicare in its CERT guidance.

Second, the government tracks error trends among certain provider types, codes, and services through the CERT program. These findings help CMS pinpoint problem areas that are perennially an issue and ratchet up the improper payment rate, costing taxpayers billions. The agency then uses this valuable information to rein in outliers, rectify issues, and promote program integrity, CGS suggests.

Lastly, CMS uses the information garnered from the report to measure how MACs are doing. The CERT data helps to determine regional programming and education, including tools like the Targeted Probe & Educate (TPE) program and Comparative Billing Reports (CBRs) in a jurisdiction.

“CERT is an excellent program that provides extremely helpful information for physicians,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department. “It’s really important for physicians to keep an eye out because there is a lot of overcharging and unnecessary billing for services that lack the proper medical necessity.”

Focus on Lab Documentation Breakdowns

You will find the improper payment rates and amounts by provider type and type of error in Table I1 and J1. Here, CMS reports that clinical laboratories logged a 19.2 percent improper payment rate, while pathology practices fared better with a 3.2 percent improper payment rate.

Of those payment discrepancies, a whopping 94 percent were attributable to insufficient documentation for clinical laboratories, compared to 84.2 percent for pathology practices. Although coding errors were negligible for clinical labs, they accounted for 11.8 percent of payment errors for pathologists.

Table G1 of the CERT report shows several lab services that demonstrate the following improper payment rates:

• Automated general profiles 9.9 percent
• Blood counts 8.9 percent
• Bacterial cultures 16.1 percent
• Routine venipuncture 10.1 percent
• Urinalysis 12.5 percent
• Glucose monitor 32.8 percent
• Other lab tests 21.4 percent

Do this: Look at some examples of what CMS considers “insufficient documentation” and check for these types of inaccuracies in your claim audits:

• Orders that are not signed by a valid physician or are missing other required elements
• Missing documentation to support the services were provided
• Documentation that doesn’t support the code reported
• No hospital record or a missing medical report
• A lack of proper authentication in the record
• Various signature issues including things like a missing or illegible signature, no signature logs, or an electronic signature with no policy or protocol attached

Bottom line: “Every dollar spent inappropriately is one that should have been used to benefit patients,” explains CMS administrator Seema Verma in a release. The agency “is pulling every lever at its disposal to safeguard precious resources and direct them to those who truly need them.”

Resources: Review the CERT report at www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf. Learn more about Medicare’s medical record documentation requirements at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf.