Comprehensive Error Rate Testing
Common CERT Errors - Cardiology
In upcoming Communiqué articles, we will be focusing on Comprehensive Error Rate Testing (CERT) errors received by specific provider specialties. This will allow us to identify documentation needs and inadequacies and the impact that these specialties have on our CERT error rate. Our focus this month is on cardiology.
Analysis of our current CERT error findings show that the most common errors assessed for this specialty involve inpatient evaluation and management services. Of these claims, the most common type of errors found were for "insufficient documentation" and "services coded incorrectly" (up-coding or down-coding).
Below is a sample of the services involved, with the CERT reviewer's comments listed below.
Services Coded Incorrectly
99255 - Initial inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history -- a comprehensive examination -- and medical decision making of high complexity.
CERT Comment: Documentation does not meet the three key components as comprehensive. Documentation supports down code to 99253, with detailed history and physical exam, and low medical decision making.
CERT Comments: Documentation supports down code to 99253, which met or exceeded 3 key components with detailed history (ROS 5 systems), physical exam (6 areas/systems), and high complexity of medical decision making.
99254 - Initial inpatient consultation for a new or established patient, which requires three key components: a comprehensive history -- a comprehensive examination -- and medical decision making of moderate complexity.
CERT Comment: Documentation supports down code from 99254, which requires 3 of 3 components (as above) to 99253, by meeting 3 of 3 components with comprehensive history, detailed exam, and medical decision making of moderate complexity.
CERT Comment: Documentation supports down code from 99254, to 99252. Documentation consists of a detailed history, expanded problem focused exam, and medical decision of moderate complexity.
Insufficient Documentation
93010 - Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.
CERT Comment: Submitted documentation of 5/18/2004 date of services. Need documentation of 10/21/2004 date of service.
CERT Comment: Submitted copies of lab and x-ray's along with the automated EKG tracing without MD signature or interpretation.
99232 - Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: an expanded problem focused interval history -- an expanded problem focused examination -- medical decision making.
CERT Comment: Submitted discharge summary for date of service 9/22/2004. Need subsequent visits by
99262 - Follow-up inpatient consultation for an established patient which requires at least two of these three key components: an expanded problem focused interval history -- an expanded problem focused examination -- medical decision making of moderate complexity.
CERT Comment: Submitted documentation included the initial cardiac consultation progress note for date of service 10/21/04. Need follow-up cardiac inpatient consultation for date of service 10/22/04.
93042 - Rhythm ECG, one to three leads; interpretation and report only.
CERT Comment: Submitted rhythm strips for this date of service are verified by RN only. No signature or progress note to confirm reading by MD/NP.
Outstanding documentation requests for Medicare Part B services furnished in an inpatient setting continue to be an area of concern that directly impacts our CERT error rate. In our attempts to obtain documentation from billing providers, both WPS and the CERT Contractor are often informed that the records are not available and we are instructed to request the necessary documentation from the facility.
Please be aware that all services billed to Medicare Part B must be documented as billed. As a Medicare provider, you must provide documentation and medical records to the CERT Contractor upon request to support claims for Medicare services. If necessary, it is your responsibility to obtain any additional documentation from a third party (hospital, nursing home, etc.).
If you have questions regarding what documentation is needed to fully comply with the CERT record request, you may contact the CERT Contractor at the number indicated on the request letter.
