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Hematology/Oncology - Specialty 83

CERT Error Examples by Denial Reason

The chart on this page illustrates the percentage each CERT denial reason contributed to the total dollars in error for Hematology-Oncology.  Insufficient documentation - 76.23%, and Service incorrectly coded - 23.77%.

Select one of the links below for error examples by denial reason or scroll through the list of all examples.

21 - Insufficient Documentation
31 - Service Incorrectly Coded


21 - Insufficient Documentation
Error Examples How to prevent this type of error
Billed Dexamethasone 1mg (x12 units), Aloxi (25mg), potassium chloride (20mg), normal saline infusions of 500ml's and 100 ml's, and mag sulfate 100mg (J1100, J2469, J3480, J3475, J7030, and J7040). Missing medical record documentation that supports the provider order or intent to order the above drugs, and missing physician attestation to support the chemotherapy flow sheet. Initially submitted documentation includes unsigned chemotherapy flow sheet, lab results, letter from provider, history and physical, progress notes and a discharge summary dated. Insufficient documentation to support services as billed.

Billed for chemotherapy administration up to 1 hour, single or initial substance/drug; chemotherapy administration, intra-arterial, up to 1 hour; chemotherapy administration, intravenous infusion, each additional sequential infusion, up to 1 hour (96413, 96422, 96417, J9265, J9045 and J7042). Missing the treating physician's authenticated orders for the chemotherapy medications and authenticated infusion record. Initially submitted consists of CT scan results, office note indicating beneficiary "tolerating chemotherapy" with Taxol and Carboplatin listed as drugs treated with; however no dose, route, or signature of individual administering drug documented. Also received office note indicating that medications were infused at a different dose than what was billed on this claim and without a signature of individual who administered the medications. Submitted documentation is insufficient to support services billed per Medicare requirements.

Provider billed for ranitidine 25 mg, 2 UOS, and gransetron 100mcg, 10 UOS (CPT 96375, J2780, and J1626). Submitted copy of chemotherapy flow sheet describing administration of billed drugs and copy of progress notes indicating medical necessity as part of chemotherapy. Missing physician's order for the drugs.
The physician must clearly document his/her the intent for all drug(s) administered, dosage, frequency and duration of chemotherapy treatment. The medical necessity of the services must also be supported. In addition, Medicare requires that all records contain a valid handwritten or electronic signature of the author of the records. Without this authentication, the records will not be considered during a medical review.

An Attestation Statement - Example is available on our WPS Medicare Website under Medical Review (MR) Forms.

For more information regarding Signature Requirements refer to the CMS Internet-Only Manual (IOM), Publication 100-08, Chapter 3, Section 3.3.2.4

For more information on coverage of these services, refer to the CMS IOM, PUB 100-04, Chapter 12, section 30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions.
Billed is chemotherapy administration (up to one hour), chemotherapy administration (each additional hour) (3 UOS) and chemotherapy administration (each additional sequential infusion) for date of service 06/21 (CPT 96413, 96415, 96417). Missing documentation of infusion stop times to support length of time each infusion was administered to determine correct administration code. Initially, received MD Protocol Order Form and medication administration form which documents medication start times yet no stop times. Also received MD Protocol Order Form for pre-medications, unauthenticated progress note and previously submitted medication administration form which now includes a late entry that documents stop times. Documentation is insufficient to support billed service.

Also billed normal saline solution. Missing physicians order for normal saline and documentation to support administration of normal saline.

In order to determine the appropriate administration codes, the start and stop time must be documented in the patient’s medical record at the time services are rendered. In addition, the medical record must contain a physician order clearly denoting the services to be rendered. Without this information, services may be denied upon Medicare claim review. We recommend periodic self-audits of medical record documentation and billing processes to avoid this type of denial.

Documentation Tips for Chemotherapy Services:

  • Clear indication of patient name, date of birth, and date of service
  • Name and dosage of drug administered
  • Infusion stop times to support length of time infusion was administered to determine correct administration code
  • Signed and dated physician order for drug(s) administered, dosage, frequency and duration of treatment
  • Progress notes to support medical necessity of the treatment
Billed for normal saline solution infusion 500cc (2 units of service). There is insufficient documentation to support that this infusion was for hydration. Chemotherapy flow sheet supports that the medications administered were mixed in the normal saline and administered via the normal saline. The hydration codes are used to report a hydration IV infusion which consists of a pre-packaged fluid and/or electrolytes (e.g. normal saline, D5-1/2 normal saline +30 mg EqKC1/liter) but are not used to report infusion of drugs or other substances. Received attestation from physician that states "that protocol for these drugs include 1,750cc of normal saline (premeds, fluids before chemo & fluids during chemo)." However, documentation submitted is insufficient to support this claim as there is no documentation of hydration on the chemotherapy flow sheet other than for hydration of normal saline 250cc. The administered drugs were mixed into normal saline and as such are not covered. Documentation does not meet Medicare guidelines. Codes for Chemotherapy administration and non-chemotherapy injections and infusions include the following three categories of codes in the American Medical Association’s Current Procedural Terminology (CPT):
  1. Hydration;
  2. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy); and
  3. Chemotherapy administration.

Physician work related to hydration, injection, and infusion services involves the affirmation of the treatment plan and the supervision (pursuant to incident to requirements) of non-physician clinical staff.

The hydration codes are used to report a hydration IV infusion which consists of a pre-packaged fluid and /or electrolytes (e.g. normal saline, D5-1/2 normal saline +30 mg EqKC1/liter) but are not used to report infusion of drugs or other substances.

A therapeutic, prophylactic, or diagnostic IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to administer the drug (s) is incidental hydration and is not separately payable.

Also as a reminder, if performed to facilitate the chemotherapy infusion or injection, the following services are included in the chemotherapy administration and are not separately billable:

  • Use of local anesthesia;
  • IV access;
  • Access to indwelling IV, subcutaneous catheter or port;
  • Flush at conclusion of infusion;
  • Standard tubing, syringes and supplies; and
  • Preparation of chemotherapy agent(s).
Payment for the above is included in the payment for the chemotherapy administration or nonchemotherapy injection and infusion service.

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31 - Service Incorrectly Coded
Error Examples How to prevent this type of error
Billed CPT 99223 requires 3 of 3 components (comprehensive history, comprehensive exam, and high complexity MDM). Documentation supports code change from 99223 to 99221 as billed with Detailed History, Detailed Exam, Moderate MDM per 1995 E/M guidelines.

Billed CPT 99232 requires 2 of 3 components (expanded history, expanded exam, and moderate MDM). Documentation supports a down code from 99232 to 99231 as billed with Problem Focused History (1 HPI) per 1995 E/M guidelines, No exam performed, LC MDM per 1995 and 1997 E/M guidelines.

Billed CPT 99233 requires 2 of 3 components (detailed history, detailed exam and high complexity MDM). Documentation supports a down code from 99233 to 99232 as billed with Expanded Problem Focused History (1 HPI/1 ROS) per 1995 and 1997 E/M guidelines, Expanded Problem Focused Exam (5 body systems) per 1995 E/M guidelines, and LC MDM per 1995 and 1997 E/M guidelines.

Billed CPT 99233. Documentation supports a down code from 99233 to 99232 as billed with Expanded Problem Focused History (1 HPI/1 ROS) per 1995 and 1997 E/M guidelines, No exam per 1995 and 1997 E/M guidelines, and moderate MDM per 1995 and 1997 E/M guidelines
Documentation for Evaluation and Management (E/M) services must support the level of service billed and the medical necessity of the level. It is also important that handwritten progress notes are legible for review purposes. For timed codes, providers should document the face to face time spent with the patient to avoid claims denials or reductions. We closely monitor our CERT errors in order to identify problem areas contributing most significantly to our jurisdiction's error rate. As a result of CERT review findings, WPS Medicare may implement pre-payment claim edits across our jurisdiction for review of problematic codes.

If you bill these services to Medicare, we highly recommend performing a self-audit of your billing and documentation processes. If Medicare overpayments are discovered, you can find instructions for submitting voluntary refunds on our Payment Recovery web page.

General Tips to consider when performing a self-audit of E/M Services:

  • Medical necessity is the overall criterion for payment in addition to the specific technical requirements of a CPT code.
  • It is not appropriate to bill a higher level of E/M service when a lower level of service is warranted.
  • The volume of documentation should not be used to determine the level of service.
  • Documentation must support the level of service reported.
  • In order to maintain an accurate record, document during or shortly after rendering the service.

Visit the WPS Medicare Evaluation and Management (E/M) web page for articles, CMS resources, and Questions and Answers (Q&As) to assist you in the proper documentation and billing of these services.

Our WPS Medicare Training page is also a great resource for upcoming educational teleconferences, on demand sessions, or in-person seminars in your area!
Billed CPT 85025 (CBC w/automated differential). Submitted treating physician's oncology flow sheet and note is for a "CBC", the treating physician did not order a WBC differential even though one was performed. Supports code change from CPT 85025 to CPT 85027 (CBC complete, automated). Documentation for services billed to Medicare must fully support the services as billed. In addition, Medicare regulations state that only services ordered by the physician should be performed and billed to Medicare. Without a valid order, the medical necessity of the billed code is not supported, and the Medicare payment must be adjusted to reflect the ordered test.

CERT reviews have noted that often times ordering forms or systems do not differentiate between "CBC" and "CBC w/differential." To avoid this type of error, we encourage you to review your system and forms to determine if they specifically include both a CBC and a CBC w/differential. If the intention is to order a CBC with differential it must be clearly noted on the order or payment will be adjusted.

Line billed for normal saline solution infusion 250cc (3 units of service). There is insufficient documentation to support that this infusion was for hydration. Chemotherapy flow sheet supports that the medications administered were mixed in the normal saline and administered via the normal saline. The hydration codes are used to report a hydration IV infusion which consists of a pre-packaged fluid and/or electrolytes (e.g. normal saline, D5-1/2 normal saline +30 mg EqKC1/liter) but are not used to report infusion of drugs or other substances. Received from an attestation from physician that states "that protocol for these drugs include 1,750cc of normal saline (premeds, fluids before chemo & fluids during chemo)." However, documentation submitted is insufficient to support this claim as there is no documentation of hydration on the chemotherapy flow sheet other than for hydration of normal saline 250cc. The administered drugs were mixed into normal saline and as such are not covered. Supports down code to 1 unit of service for 250cc normal saline. Only fluids used for hydration should be reported as such. If used to facilitate the chemotherapy infusion or injection, the saline is not separately payable.

If you bill these services to Medicare, it is important that your billing staff is aware of this coverage regulation. We recommend a self-audit of your medical records and billing to determine if you are complying with Medicare requirements for these services.

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Page Last Updated: Tuesday, 19-Aug-2014 10:46:26 CDT