Performing and Billing Medicare Services as Ordered
Recent data analysis and claim review findings by the Comprehensive Error Rate Testing (CERT) contractor, as well as by WPS Medicare, have identified some repetitive billing and documentation issues among providers billing Medicare allowable services. The identified issues include services being provided that are not ordered by the physician, and billing for services provided but not ordered.
CMS regulations state that the physician must clearly order tests and services to be performed and only services ordered by the physician should be performed and billed to Medicare.
Per the Centers for Medicare & Medicaid Services (CMS) Benefit Policy Internet Only Manual, Publication 100-02, Chapter 15, Section 80.6.1: An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y).
This section of the regulations also contains, information regarding when an order is clinically inappropriate or suboptimal, and a different diagnostic test should be performed, when the result of an ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should be performed, as well as rules for the testing facility interpreting physician to furnish different or additional tests.
Recent Comprehensive Error Rate Testing (CERT) reviews for services billed under CPT 85025 or CPT 85027 have found instances where either the documentation, or the physician order, does not support the service billed to Medicare. One example of recent findings from the CERT contractor include:
- If a physician orders a "CBC," then only a CBC without differential, 85027, should be performed and billed.
- If a physician orders a "CBC with differential," then only a CBC with differential, 85025, should be performed and billed.
Recent Medical Review findings from WPS Medicare have yielded similar results where the documentation, or the physician order, does not support the service billed to Medicare for bone mass measurement testing. Some examples of recent findings from WPS Medicare include:
- If a physician orders a Dual Energy X-ray Absorptiometry (DEXA or DXA), 77080, then only a DEXA scan should be performed and billed.
- If a physician orders a scan and the facility does not have the capabilities of performing that type of scan, then the facility must seek a new order for the type of scan available from the physician before the scan is performed.
These examples are a few of the identified issues where a facility is not performing what the physician ordered, or what was ordered was not completed and billed.
REMEMBER: The billing provider has the ultimate responsibility to obtain and provide copies of medical records to support services billed, even if the records are housed elsewhere (i.e. physician's office). Insufficient documentation and incorrect coding can result in recoupment of Medicare payment.
Page Last Updated: Thursday, 18-Mar-2010 05:48:32 CDT
