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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.  Medically unnecessary service or treatment - 48.94%, Service incorrectly coded - 24.48% and Insufficient documentation - 23.58%.

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

21 - Insufficient Documentation
25 - Medical Unnecessary Service or Treatment
31 - Service Incorrectly Coded


21 - Insufficient Documentation
Error Examples How to prevent this type of error
Billed CPT 82040, 82247, 82310, 82435, 82565, 83615, 83735, 84075, 84132, 84155, 84295, 84450 and 84460. Missing is the physician's order/intent to order billed laboratory studies Serum Creatinine, Chloride, Potassium, Albumin, Sodium, Total Bilirubin, Alkaline Phosphatase, Total Protein, Total Calcium, SGOT, SGPT, LDH, Magnesium for 5/2/2011. Received are Laboratory results and progress note for 11/08/2010. After follow-up requests received same information as originally submitted and physician attestation and a form with routine lab orders that is not complete. Attestation received does not indicate order or intent to order billed lab studies. No orders received. Documentation of beneficiary with breast Ca supports medical necessity. Lacking physician orders to support service as billed. In addition to documentation of the results of diagnostic tests, Medicare requires a physician order and documentation of medical necessity. Periodic self audits of your medical record documentation and subsequent education of your staff can assist in avoiding these types of errors.

Per CMS Internet-Only Manual, Publication 100-02, Chapter 15, Section 80.6.1,
"All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary". A signed physician's order is not required for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services. However, there must be clear documentation by the physician in the medical record (e.g. progress note) of his or her intent that the test be performed. A signature attestation statement is not acceptable for unsigned orders, but is acceptable from the performing provider for unsigned progress notes.
Billed is CPT code J1200-Diphenhydramine (Benadryl) up to 50mg, J2780-Ranitidine 25mg, and PT code J9045- Carboplatin injection 50 mg on 12/27/10 (in addition to 96375, 96413, 96415, 96417, J1260, J1100, J7030, J7040, J7050, J1642). Missing the order for dose of Carboplatin injection 50 mg -6 units. Submitted documentation included Medication administration record dated 12/27/2010, physician signature log, physician progress notes with medical necessity and plan for continued chemotherapy with Taxol /carboplatin (no dosage given) dated 10/01/2010, physician signed chemo protocol order form dated 10/19/2010 also missing dose to be administered and treatment initiation form dated 10/19/2010 that list Carboplatin however missing amount to be administered. Missing order for billed Diphenhydramine hcl injection, treatment initiation form that list Diphenhydramine hcl injection 25 mg however has ending date of 11/01/10 which does not include billed date of service and note to CERT "...new start date for the new cycle regimen should have been edited by the nurse....error on nurse's part" signed by office staff. Insufficient documentation to support billed service per Medicare guidelines. Billed Ranitidine 25mg 2 units, is related to the billed Carboplatin injection that was denied therefore Ranitidine is also not covered. Also missing order for billed Ranitidine.

Billed CPT 96360- Hydration IV infusion initial 31 minutes to 1 hour. Missing requested physician order for intravenous infusion. Submitted includes chemotherapy flow sheets documenting 500 ML of normal saline given, orders for pegfilgrastim 6mg and multiple office visit notes. Documentation submitted does not meet requirements Medicare guidelines.

Billed CPT 96375, HCPCS J1626 and J2780. Submitted records include chemotherapy order listing Taxol and Diphenhydramine. Missing treating physician's order for Granisectron (Kytril) and Ranitidine (Zantac). Submitted copy of chemotherapy flow sheet describing administration of billed drugs and copy of progress notes indicating medical necessity as part of chemotherapy, but missing physician's order for the drugs.
In addition to documentation to support medical necessity, and the administration of chemotherapy treatment, Medicare requires a signed and dated physician order for all drug(s) administered, to include the dosage, frequency and duration of treatment. Drugs not properly documented on the order or progress note will be denied.

We recommend period self audits of your medical record documentation and billing to ascertain if issues exist which could result in claim denials. Additional education of your practitioners may also be needed.

For more information on coverage and documentation of these services, please refer to the WPS Medicare Local Coverage Determination (LCD) for Chemotherapy Drugs and their Adjuncts.

Also refer to the WPS Medicare On Demand Training web page for additional training at your convenience.
Billed HCPCS J7040 - 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. Provides should be aware of proper billing of these services. 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).
For more information, refer to the CMS Internet-Only Manual, Publication 100-04, Chapter 12, section 30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions.

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25 - Medical Unnecessary Service or Treatment
Error Examples How to prevent this type of error
Billed 96375, 96413, 96415, 96417 and HCPCS J1100, J1260, J7030, J7040 and J7050. All services were related to Carboplatin injection which was denied due to lack of a physician order. Therefore these related services are considered not medically necessary. A valid order must be submitted for all chemotherapy drugs administered. Without this documentation, all related services on that date of service will be denied as not medically necessary. To avoid these denials, practitioners must ensure that all services are included on the order for the course of treatment. Changes should also be documented promptly.

Refer to the following CMS resources for further guidance:
CMS Internet-Only Manual (IOM), Publication 100-4, Chapter 16, section 180 (services related to and required as a result of services which are not covered under Medicare).

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31 - Service Incorrectly Coded
Error Examples How to prevent this type of error
Billed HCPCS J7050 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 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.
Evaluation and Management (E/M) Services Coded to Lower Level by CERT Reviewer

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, Low 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 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 Low 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. Incorrect coding of E/M services is a significant contributor to CERT error rates and can lead to further review by WPS Medicare of providers who bill these services. A self-audit is an excellent proactive measure for a physician practice to ascertain if any problem areas exist which may warrant further education or corrective actions.

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 web page for articles, CMS resources, and Frequently Asked Questions (FAQs) to assist you in the proper documentation and billing of these services.

Our WPS Medicare Training web page is also a great resource for upcoming educational teleconferences, on demand sessions, or in-person seminars in your area!

Also view the CMS MLN Fact Sheet: Evaluation and Management (E/M) Services: Complying with Documentation Requirements
Initial Evaluation and Management (E/M) CPT Codes Re-Coded to Subsequent Visit Codes by CERT Reviewer

Billed CPT 99223 requires 3 of 3 key components; comprehensive history, comprehensive exam, and medical decision making (MDM) of high complexity. Per the submitted documentation, history was detailed, exam was expanded problem focused, and MDM was moderate. Supports re-code to subsequent visit CPT 99232.
Evaluation and Management services billed as initial visits must be medically necessary and must meet minimum components of the CPT code billed in order to be payable at the level billed. CERT reviews have shown cases of incorrect coding for those services previously reported under consultations codes.

Refer to CMS Internet-Only Manual, Publication 100-04, Chapter 12, section 30.6.9.F- F. - Initial Hospital Care Service History and Physical That Is Less Than Comprehensive which states:

"Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT consultation codes (99241 - 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements. Physicians must meet all the requirements of the initial hospital care codes, including "a detailed or comprehensive history" and "a detailed or comprehensive examination" to report CPT code 99221, which are greater than the requirements for consultation codes 99251 and 99252.

"Subsequent hospital care CPT codes 99231 and 99232, respectively, require "a problem focused interval history" and "an expanded problem focused interval history." An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 - 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay."

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Page Last Updated: Tuesday, 15-Jul-2014 09:23:00 CDT