Knowledge Base Article

One Medicare contractor that we do not talk a lot about, especially concerning outpatient services, is the Comprehensive Error Rate Testing (CERT) contractor. The purpose of the CERT program is to calculate the Medicare Fee-for-Service (FFS) improper payment rate. Improper Payments statutory requirements compel federal agencies to annually review programs they administer in order to reduce and recover improper payments. CERT measures the payment compliance of the Medicare Administrative Contractors (MACs) by evaluating a statistically valid stratified random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. It is sort of a “report card” for the MACs. The random sampling makes CERT very different from other Medicare reviewers who select targets at potential “high risk” of noncompliance based on data analysis and findings from other reviews. In fact, the MACs often target their medical reviews based on the findings of the random CERT audits.

The reasons we do not discuss CERT findings much are the random nature of the audits and the more general types of findings that are published from CERT outpatient reviews. For outpatients, we often see errors such as missing signatures, lack of a signed order, or a missing report. CERT findings for an individual hospital are shared with that hospital and afford an opportunity to identify any potential system issues. However, a recent article by Palmetto GBA, the MAC for Jurisdictions J and M, about the top CERT errors for Jurisdiction J included some detailed examples of errors that are good lessons for all providers beyond missing signatures, orders and reports. You can find the article here. I encourage providers to check their MAC’s website for information on CERT findings for your jurisdiction.

You can read about all the common errors at the link above, but a few of them particularly caught my attention.

Psychiatric Admission

The common CERT error for psych admissions was medical records missing the physician-signed multidisciplinary treatment plan. This caught my attention because psychosis DRG 885 is a Targeted Probe and Educate review topic for Palmetto (JJ and JM) and First Coast (JN). As a result, I have written about the documentation requirements for psychiatric admissions before and one of my co-workers has recently performed an audit of psych records. Here is information about psych documentation requirements from a prior Wednesday@One article.

Psychiatric admission documentation should include:

• A psychiatric treatment plan developed within the first 3 days of admission that contains
• a substantiated diagnosis;
• short-term and long-range measurable, functional, time-framed goals;
• specific treatment modalities; and
• responsibilities of each treatment team member.
• Treatment plan updates documented at least weekly that are reflective of active treatment and that note changes in type, amount, frequency and duration of the treatments as well as the patient’s progress or lack of progress.
• Psychiatric evaluation and progress notes demonstrating clear evidence the acute psych condition requires active treatment in an inpatient psychiatric setting.
• An initial certification of psychiatric services signed by the physician and including documentation the services can reasonably be expected to improve the patient’s condition or are for diagnostic study.
• Recertifications supporting the medical necessity of continued care - the first by the 12th day of admission and then at least every 30 days thereafter.

Defibrillators/AICD—National Coverage Determination (NCD) 20.4

The common errors for Automatic Implantable Cardiac Defibrillators (AICDs) included:

• “Providers are not submitting physician progress notes to support the medical necessity of the device
• Missing formal shared decision making encounter between the patient and a physician using an evidence-based decision tool on ICDs prior to initial ICD implantation”

This is note-worthy because implantation of AICDs has a large reimbursement rate, generally over $25,000 so it would be a significant financial loss for a hospital for this service to be denied. NCD 20.4 has very detailed coverage requirements so if you perform these services, make sure you are familiar with and follow the requirements. To support the medical necessity of the service, you will need documentation from the physician’s office, such as history and physical and/or progress notes that describe the patient’s condition and the reasons the procedure is needed. You also need to include in the current medical record reports of relevant diagnostic testing and notes describing prior treatments and interventions including the patient’s response.

A term we are seeing more and more these days is “shared decision making.” The AICD NCD has the most descriptive requirements of what documentation is expected, requiring the use of an evidence-based decision tool to document the physician’s discussion with the patient about the risks versus the benefits of proceeding with the procedure. This requirement was added to NCD 20.4 in the February 2018 NCD revision, but the MACs did not implement the new NCD until March 2019. Remember however, that the effective date of the NCD revisions is February 15, 2018. For all claims your hospital submits after the implementation date, the formal SDM tool is required for dates of service on and after February 15, 2018.

Other coverage policies, both national and local, are beginning to include requirements for shared decision making. For example, it is part of NCD 20.34 for Percutaneous Left Atrial Appendage Closure (LAAC) (also known as the Watchman procedure). This NCD requires, “A formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the shared decision making interaction must be documented in the medical record.”

And in Palmetto’s new Local Coverage Determination (LCD) for Lumbar Spinal Fusion, we find the following:

“Where possible, there must be documented shared decision making with the patient or the individual who is serving as the proxy decision maker for the patient with the appropriate discussion of anticipated risks and benefits of the procedure…. Outcomes for fusion in revision surgery, usually do not lead to pain relief and as such fusion is considered a last resort treatment option only when all other treatment options have failed. This information must be communicated to the patient prior to surgery to allow for appropriate shared decision making with a well-informed patient. The medical record must reflect that this counseling was done and that the patient wished to undergo surgery with the appropriately informed consent.”

I think a well-informed patient is a good thing and I applaud CMS for beginning to make this a documented requirement. This documentation of shared decision making goes beyond a surgical consent – it should include the risks and benefits that were discussed with the patient. The tools CMS recommends for AICD and the Watchman procedure SDM make it easy to know what to include – in Palmetto’s Spinal Fusion LCD the SDM requirements are left up to the physician as to what should be included and how it should be documented. Providers should not skim over this however, as I expect Medicare reviewers will be looking for this documentation for all services that require it. I appreciate the challenge this may present for physicians especially with elderly patients who have declining cognitive abilities. In this case, the physician may need to document a discussion with a family member or friend or whoever is serving as the proxy decision maker for the patient.

Physicians and other providers can find information on the Agency for Healthcare Research and Quality (AHRQ) website about AHRQ’s SHARE Approach, “a five-step process for shared decision-making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.”

Cataract Surgery

Speaking of the challenges of elderly patients, the CERT common error for cataract surgery caught my eye (unintended pun) because my mother has recently had cataract surgery on one eye and will undergo the second eye surgery soon. The error was the lack of documentation “to support the beneficiary’s own assessment of his/her functional status (usually in the form of a patient questionnaire).” I do not recall that I or my mother completed such a form, but had she filled it out she would have said she could see “fine.” However, we did have that discussion with the doctor, with my mother saying she could see just fine, and me insisting that lack of clear vision was causing issues with her activities of daily living. Hopefully the physician documented that conversation for justification of his and the facility’s Medicare payment.

Another common error listed for cataract surgery was that providers are only submitting documentation for the affected date of service. As you can tell from the above discussions about including diagnostic test results, prior treatments and physician office notes, documentation from only the procedure date of service would be lacking much critical information to support the services were medically necessary.

These are good lessons that contain some excellent learning points from CERT findings. Check the MAC websites (especially your own MAC’s) and review your hospital’s CERT report for more potential lessons from the CERT reviews. By being proactive, the CERT can be another education opportunity instead of just another means to deny your Medicare claims.