Knowledge Base Article

Annually, the Comprehensive Error Rate Testing (CERT) program measures improper payments in the Medicare Fee-For-Service (FFS) program. As shared in a related MMP article, “improper payment rates are not necessarily indicative of or are measures of fraud. Instead, improper payments are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements and may be overpayments or underpayments.” This article focuses on the trend in common causes of improper payments.  

Fiscal Year 2020 Supplemental Improper Payment Data - Common Causes of Improper Payments

The CERT groups improper payments into five categories. The following table compares common causes of improper payments broken out by the type of error for past four years. While Medical Necessity and Incorrect Coding errors are on the decline, there is an increasing trend in the percentage of errors due to insufficient documentation.

Insufficient Documentation

The increase in “insufficient documentation” errors is further evidenced in the 2020 Report, Table D4: Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS. It should come as no surprise that the DRGs in this table with a high percentage of “insufficient documentation” errors are surgical procedures. Following are DRGs in Table D4 with an Insufficient Documentation error greater than 90%.

DRGs 266 & 267: Endovascular Cardiac Valve Replacement

In the 2020 Report, 97% of the overall error rate for this DRG pair was attributed to Insufficient Documentation. Structural heart procedures Transcatheter Aortic Valve Replacement (TAVR) and Transcatheter Mitral Valve Repair (TMVR) both sequence to DRGs 266 & 267. Both procedures have a related National Coverage Determination (NCD) outlining the requirements for the procedures to be considered medically necessary. (TAVR NCD 20.32 and TMVR NCD 20.33).

June 30, 2020, CMS released a Proposed Decision Memo for TMVR procedures and includes significant changes in coverage indications. The comment period ended July 30, 2020. The Final Decision memo should have been published in September 2020. Well past the September 2020 deadline, CMS finally published the Final Decision Memo (CAG-00438R) on January 19, 2021. At first glance, there are significant changes in the Final Decision Memo when compared to what was proposed.

DRGs 273 & 274: Percutaneous Intracardiac Procedures

In the 2020 Report, 100% of the overall error rate for this DRG pair is attributed to insufficient documentation. The structural heart procedure Left Atrial Appendage Closure (LAAC) sequences to DRGs 273 and 274. Similar to the TAVR and TMVR procedures, the LAAC procedure has an NCD.

DRGs 226 & 227: Cardiac Defibrillator without Cardiac Cath

In the 2020 Report, 90.8% of the overall error rate for this DRG pair is attributed to insufficient documentation. The related coverage determination is NCD 20.4. Additionally, almost all Medicare Administrative Contractors have published a Local Coverage and Billing Article.

Cardiac Defibrillator Shared Decision Making

NCD 20.4 was revised in 2018 and now requires documentation of Shared Decision Making with the patient prior to the procedure being performed. This continues to be challenge for hospitals.

In the Public Comment section of the February 18, 2018 Cardiac Defibrillator Final Decision Memo (CAG-00157R4), CMS responded to a comment with the following statement:

“CMS believes in the importance of an evidenced based tool but they are not specifying the type of tool that is required. They do provide an example of an evidence based decision aid for patients with heart failure who are at risk for sudden cardiac death and are considering an ICD. This tool was funded by the National Institutes on Aging and the Patient-Centered Outcomes Research Institute and can be found at https://patientdecisionaid.org/wp-content/uploads/2017/01/ICD-Infographic-5.23.16.pdf. CMS notes that this tool is based on published clinical research and interviews with patients and includes discussion of the option for future ICD deactivation.”

On December 21, 2020, WPS, the Medicare Administrative Contractor for Jurisdictions 5 and 8, posted the following information in their e-newsletter:

“The Comprehensive Error Rate Testing (CERT) contractor recently issued errors related to formal shared decision making encounter using an evidence-based tool prior to ICD implantation. In these cases, submitted emergency room, history and physical, consultation, and other progress notes did not include adequate documentation to support this encounter took place prior to surgery.

For more information regarding coverage criteria for ICDs, see the CMS Internet-Only Manual (IOM) Publication 100-03, Chapter 1 , section 20.4.”

As recent as last week, Palmetto GBA, the Medicare Administrative Contractor for Jurisdiction J and M, announced a new education module available to providers related to DRG 227. They indicate that the “purpose of this module is to educate providers on this DRG so claims can be submitted correctly.”

Moving Forward

Preventing “insufficient documentation” errors is not an insurmountable challenge. It is important to identify when a procedure has a related National or Local Coverage Determination. If the answer is yes, read the NCD carefully and make sure you are following all of Medicare’s requirements to support the medical necessity for the procedure and make sure the information is documented in the record.