National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007- 11AB, November 2007

Comprehensive Error Rate Testing - November 2007 

Recent common Comprehensive Error Rate Testing ( CERT) errors have been identified and posted as educational information for providers. The following are examples of some recent CERT errors assessed to National Government Services. Internal auditing in the provider office is recommended to help identify potential coding issues that may need monitoring or correction. Many of the errors are preventable billing errors. Please review them carefully to help prevent occurrence within your own billing office setting. Additional educational information is available on the Centers for Medicare & Medicaid Services ( CMS) and National Government Services Web sites.

CPT 36415 - Documentation submitted is finger stick glucose and Hemoglobin A1C performed in the office for billed service date. No lab results submitted or noted in Common Working File (CWF) for service date billed to support a venipuncture was performed.

CPT 82962 - Routine glucose monitoring of diabetics is never covered in a skilled nursing facility (SNF), whether the beneficiary is in a covered Part A stay or not. The claim with bill type 221 was submitted with CPT 82962- Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use. Glucose monitoring may only be covered when it meets all the conditions of a covered laboratory service, including use by the physician in modifying the patient’s treatment. No documentation was submitted to support that accuchecks were other than routine glucose testing.

HCPCS J2405 - Ondansetron hydrochloride injection; per 1 mg. Documentation supports change of billed unit of service from 1 unit to 24 units, in that 24mg of Zofran was administered on billed date-of-service.

CPT 97110 - Therapeutic procedure, one or more areas, each 15 minutes. There is insufficient documentation to support the billed physical therapy (PT) services. Per the local coverage determination (LCD) documentation requirements, “Documentation must demonstrate that the beneficiary’s physician is actively participating in the care rendered by the physical therapist and has certified its medical necessity. ICD-9-CM codes in support of medical necessity must be submitted with each claim.” There is no documentation of physician involvement. There is not a PT order or certification, or a physician’s signature on any of the documentation submitted. Additionally, the ICD-9-CM code submitted does not meet the LCD for medical necessity.

CPT 97032 - Received a note stating: “We are unable to locate the records requested (occupational therapy, date of service 4/30/2007) and will refund the payer immediately.” Missing documentation of billed OT services. Denied service billed as not rendered.

HCPCS A0425 - (Ground Mileage, per statute mile) with 1 unit billed. Submitted documentation lists mileage and loaded mileage as 16. Change units from 1 to 16.

CPT 84134 - (Prealbumin) Insufficient documentation; missing laboratory test results for Prealbumin for billed date of service 04/25/2007. Provider notified CERT, in part, “When the biller fixed the outpatient claim she dated all of the charges for 04/25/2007. However, one test, the Prealbumin, should have been for date of service 04/27/2007.”

CPT 93010- Electrocardiogram, routine ECG with at least 12 leads; interpretation and report. Missing copy of the report or the progress notes from the ER for billed date of service 04/03/2007 to support billed services.

CPT 98941 - CMT; spinal, three to four regions) was changed to CPT 98940 (CMT; spinal, one to two regions). Documentation was received noting adjustment of thoracic and cervical spinal areas on billed dates of service and also received documentation of adjustment, of right wrist, pronator teres, and right pelvic deficiency on billed dates of service. Per the Internet Online Manual ( IOM) Pub 100-2, Chapter 15, Section 240.1.4: The areas of the spine are neck, back, low back, pelvis, and sacral. Per the LCD, Medicare does not cover chiropractic treatment to extra spinal regions (head, upper, and lower extremities, rib cage, and abdomen).

CPT 99243 - (Requires 3 of 3; detailed history; detailed exam; low complexity medical decision making). Documentation supports a down code to 99242 with an expanded problem focused history; expanded problem focused exam (limited exam of each organ system) and low complexity medical decision making per 95 Evaluation & Management (E/M) guidelines. Presenting problem is of low severity.