Knowledge Base Category -

Can you sometimes tell by the tone of someone’s voice or the way they drag out the words, that there is a condition to their answer? “Well, nooo…” You just know the conjunction “but” is coming. Medicare generally communicates with providers in writing, but experience tells us there is often a condition to Medicare’s answers.

A few years ago there was a lot of discussion in Medicare billing circles about whether a physician’s signature is required on a laboratory requisition. And in typical Medicare fashion, the answer was a clear, “No…, but…” The “but” being that although the signature of the ordering physician is not required on the requisition, there has to be an order or documentation of intent to order the lab tests that is signed by the physician. This documentation can be located in the physician’s office chart, but needs to be submitted to the Medicare contractor in the case of a medical review of the claim. And the provider being reviewed (i.e. the testing lab), whose payment is at risk, is the one ultimately responsible for submitting the supporting documentation.

With all the reminders of these requirements that circulated back then, surely most hospital-based and independent laboratories understood what was expected. Therefore, I was a bit surprised to see an announcement back in December concerning a significant increase in pathology and laboratory service errors identified by data analysis of the Comprehensive Error Rate Testing (CERT) program findings. In response to the increase in errors, CERT published a document addressing the lab and pathology errors.

CERT identifies insufficient documentation and incorrect coding as the reasons for the significant errors, but the main issue addressed in the publication is missing or incomplete documentation.

“If a physician’s order for a diagnostic test is not included in the medical record, the physician must document the intent to order the laboratory service.” This documentation must state the specific tests the physician is ordering. Simply stating “ordering lab” is not sufficient. Also the documentation of intent must be signed by the physician or there must be a signed physician’s order for the lab tests. A signed order or signed documentation of intent to order must be sent to the Medicare contractor reviewing the record to support the services billed. Without this documentation, the claim will be denied.

“Documentation must support the medical necessity for the services performed.” Per the Medicare Claims Processing Manual, Chapter 16 , section 120.1 – “Diagnoses are required on all claims” and such diagnostic information must be supplied to the performing laboratory by the ordering physician. There are twenty-three National Coverage Determinations (NCDs) for lab services and individual Medicare Administrative Contractors (MACs) often have Local Coverage Determinations (LCDs) for other lab services. Both the NCDs and LCDs require certain diagnoses to support the medical necessity of the lab tests; additional indications and documentation may also be required by the coverage policies. Two examples of required lab documentation from the CERT document include:

• Blood Glucose - The ordering physician must include evidence in the patient’s clinical record that an evaluation of history and physical preceded the ordering of glucose testing and that manifestations of abnormal glucose levels were present to warrant the testing.
• Thyroid Function tests - When thyroid function tests are billed at a greater frequency than the norm (two per year), the ordering physician’s documentation must support the medical necessity of this frequency.

One more requirement – signatures must meet the Medicare signature guidelines as described in the Medicare Program Integrity Manual, Chapter 3, section 3.3.2.4.

In summary, if the CERT contractor reviews your laboratory claims, be sure to:

1. Respond timely to the CERT medical record request
2. Providers have 75 days to submit requested records
3. CERT will accept late documentation
4. Include all necessary documentation
5. A signed order or documentation of intent to order labs signed by the ordering physician
6. Signatures must meet Medicare signature requirements
7. Documentation to support the medical necessity of the services
8. Lab results/reports
9. Appeal unfavorable decisions to your local MAC
10. Include additional supporting documentation

That “no signature” thing comes with a huge conditional “but”!

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Medicare has recently added yet another review contractor to audit your claims – the Supplemental Medicare Review Contractor (SMRC). So why does CMS need so many contractors to fight improper payments and ensure compliance? And what are the differences between the different contractors? I am not sure the answers are really clear, but here is some information from a recent transmittal about the various contractors and their functions.

CMS Transmittal 508 updates the Medicare Program Integrity Manual to include information about the Supplemental Medicare Review Contractor. According to the manual update, SMRCs, along with CERT contractors, Medicare Administrative Contractors (MACs), and Recovery Auditors (RAs) are contracted by CMS to fight improper payments and promote provider compliance in the Medicare fee-for-service program.

CERT Contractors

The CERT program establishes error rates and estimates of improper payments (implemented as part of the Improper Payments Elimination and Recovery Improvement Act).

Medicare Administrative Contractors (MACs)

MACs prevent improper payments through initiatives to help providers comply with Medicare’s coverage, coding and billing rules. This is accomplished through provider education; pre-and post-payment claim review; and local coverage determinations (LCDs), articles, and coding instructions. The MACs use error rates and vulnerabilities identified through the CERT and RA programs to target their efforts.

Recovery Auditors

Because of the large volume of claims that Medicare processes and the difficultly with catching all improper payments, the RAs provide additional review to detect and correct improper payments to help protect the Medicare Trust Funds.

Supplemental MR Contractor (SMRC)

The SMRCs are a centralized medical review (MR) resource that can perform large volume MR nationally. They perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. The focus of SMRC reviews may include but are not limited to issues identified by CMS internal data analysis, the CERT program, professional organizations and other Federal agencies, such as the OIG/GAO and comparative billing reports. Their primary duties include:

• Serving as a readily available source of medical information to provide guidance in questionable situations, including questionable claim review situations
• Providing the clinical expertise and judgment to develop LCDs and internal MR guidelines
• Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse
• Providing clinical expertise and judgment to effectively focus MR on areas of potential fraud and abuse

Are the differences between the contractors clear as mud? Yes, I thought so. But even so, you need to know who the Medicare contractors for your region are. You can find that information by using the Review Contractor Directory.

As the summer winds down and school is fast approaching, it takes me back to all the hours of taking notes, studying and then having to take tests. Just like a test in school is a reflection of
how well you have learned what you are being taught, in the world of Medicare & Medicaid Review Contractors the Comprehensive Error Rate Testing (CERT) Contractor performs audits to see how well Medicare Administrative Contractors (MACs) are adjudicating claims.

Error Rate Testing, a Historical Perspective:

• From 1996 through 2002 the HHS Office of Inspector General (OIG) estimated the Medicare Fee-for-Service (FFS) error rate.
• The Centers for Medicare and Medicaid Services (CMS) took over responsibility for the error rate measurement programs in FY 2003. At this time the sample size for the program increased from approximately 6,000 claims to approximately 120,000 claims thus allowing for the projection of a national error rate and for the first time for contractor and service level error rates.

CERT Review Process:

• The purpose of CERT reviews is to measure improper payments.
• The volume of claims reviewed is small.
• Claims are randomly selected from all claims submitted for payment.
• Claims reviewed are only post-payment complex reviews.
• The CERT Documentation Contractor requests medical records.
• If a provider does not submit the requested record, this counts as an improper payment and the payment is recouped from the providers.
• At least one nurse at the CERT Review Contractor will review the claim.
• Claims that are determined to be incorrect are scored as an error and payments are adjusted.
• Major Causes of Improper Claims includes:
• Missing Physician orders
• Illegible or missing signatures
• National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) not being met; and
• The medical record does not support the medical necessity.

2010 CERT Report by the Numbers:

The CERT publishes an annual Improper Payment Report. The most recent report released November 22, 2011 reports the error rate and findings for 2010.

• The 2010 Medicare Fee-for-Service (FFS) paid claims error rate was 10.5% which equates to $34.3 billion in improper payments.
• Improper payments for inpatient hospital claims increased significantly from 2009 with inappropriate “place of service” errors accounting for a projected $5.1 billion.
• The Medicare Part B error rate decreased from 18.9% in 2009 to 12.9% in 2010.
• The Medicare Part A non-inpatient hospital claims decreased from 8.8% in 2009 to 4.2% in 2010.

What does the Medicare Administrative Contractor (MAC) do with the CERT Findings?

• Utilizes the findings to determine issues for Provider Education and Pre-Payment Reviews.

To learn more about the CERT visit the CMS CERT web page.