August 26, 2013

The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare Fee-for-Service (FFS) program.  CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012.  IPIA and IPERIA require the heads of Federal agencies, including the Department of Health and Human Services (HHS), to annually review programs it administers to improve agency efforts to reduce and recover improper payments.

The Medicare FFS improper payment rate was first measured in 1996. HHS Office of Inspector General (OIG) was responsible for estimating the national Medicare FFS improper payment rate from 1996 through 2002. Based on available resources, OIG reviewed about 6,000 claims.  Currently CERT selects a stratified random sample of approximately 50,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs) during each reporting period.  This sample size allows CMS to calculate a national improper payment rate and contractor- and service-specific improper payment rates.  The CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period.

The sample of Medicare FFS claims is reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage, coding, and billing rules.  If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments).  The last step in the process is the calculation of the annual Medicare FFS improper payment rate, which is published in the HHS Agency Financial Report (AFR). 

It is important to note that the improper payment rate is not a “fraud rate,” but is a measurement of payments that did not meet Medicare requirements.  The CERT program cannot label a claim fraudulent.  Improper payments that should not have been made or payments made in an incorrect amount (including overpayments & underpayments) include:

• Payment to an ineligible recipient
• Payment for an ineligible service
• Any duplicate payment
• Payment for services not received
• Payment for an incorrect amount

All public reports produced by the CERT program are available through the "CERT Reports" link on the CMS website.

A review of the available CERT reports shows several items of potential interest to anesthesiologist and pain management providers.  These include:

• Per SSA 1833(e), and IOM PUB 100-8 Chapter 3 § 3.4.1.1D (Signature Requirements). No provider signature. Billed (2) units monitored anesthesia care for 2/21/2011 with HCPCS code 00740. Missing anesthesiologist's signature on anesthesia record.  Received e-signed EGD procedure report and anesthesia flow sheet signed only by CRNA; cannot determine if this unsigned record is a complete anesthesia record or just one page.
• In the 2011 review period, a claims processing contractor paid $152.95 for anesthesia used during a routine dental extraction for dental care.  As services associated with a non-covered service (dental extraction) are not allowed, the entire amount was recouped by the claims processing contractor.
• Per SSA 1833(e), CPT 2011, 1995 E&M Guidelines, and PUB 100-4 Chapter 12, § 30.6.12 (Critical Care), § 30.6.1(Selection of Level of Evaluation and Management Service). Service 99291 is incorrectly coded.  Submitted for Date of Service 06/11/2011 is documentation of subsequent hospital visit by the physician. Although the MD does document 38 minutes of service, based on submitted documentation neither the beneficiary's condition nor service provided meets the requirements of critical care service.  Submitted documentation from the visit supports recode from CPT 99291 (Critical Care; first 30-74 minutes) to CPT 99233 Subsequent Hospital Care per 1995 E&M guidelines.  Service documented meets 2/3 required elements for CPT 99233. 
• Billed Transforaminal epidural injection services (J1030, 64483-LT, 64484-LT, 99212-25, 72275-59). Missing documentation of a separate distinct vertebral level, as well as the initial history and exam, pain effects on disability, severity of pain and response to prior injections.  The procedure note submitted included the physician's statement "the left L4-5-S1 vertebra was identified by fluoroscopy" and "the spinal needle was advanced toward the transforaminal epidural space at left L3-5-S1 region under fluoroscopic guidance."  Missing documentation of epidural injection of a separate distinct vertebral level.  Missing an epidurogram report to support the billing of the epidurogram with the 59 modifier.  Also, there is no separate progress note or other documentation submitted to support a separate evaluation and management service was performed.
• Billed lumbar or sacral spine injection, fluoroguide for spine injection, and Methylprednisolone 80 mg injection (CPT 62311, 77003, J1040).  Missing the treating physician's clinical documentation of the beneficiary's pre- and post-evaluation documenting the beneficiary's response to the injection, including pain level and ability to perform previously painful maneuvers as required by LCD.¹

Since 2003, CMS and MACs have analyzed the improper payment rate data and developed Error Rate Reduction Plans to reduce improper payments.  Corrective actions include:

• Refining improper payment rate measurement processes
• Improving system edits
• Updating coverage policies and manuals
• Conducting provider education efforts

On August 20, 2013, all the MACs joined forces in a national conference call to announce the formation of a new combined Part A and Part B Medicare Contractors CERT Task Force (A/B Task Force).  The CERT Task Force will be addressing common educational issues between the MACs in an effort to help reduce the Medicare improper payment errors.  This new initiative is independent from the CERT team and current CERT Contractors’ roles.  During the conference call, the Part A and Part B MACs  provided an overview of the Task Force objectives and how they plan to proceed in the next few years.  The MACs’ view this new partnership as a benefit to the provider community in that this level of collaboration and consistency will help to reduce costly claim denials.  The role of the A/B Task Force will be to:

• Support CMS’ CERT error rate reduction goals
• Promote educational collaboration among MACs
• Improve consistency between MACs
• Develop collaboration to improve MACs knowledge and performance

The Task Force is hoping to help CMS reduce the 2012 improper payment rate of 8.5 percent in fiscal year (FY) 2012.  Medicare’s total payment in FY 2012 was $349.7 billion, with CERT identifying $29.6 billion as improper payments.  The goal is to reduce the improper payment rate down to 8.3 percent in FY 2013.²

During the August 20 national call, the A/B Task Force announced they will start by collaborating on medical documentation issues and physical therapy issues.  As demonstrated by a review of the type of anesthesia and pain medicine CERT errors identified to date, the provision of clear examples of what documentation the CERT contractor is looking for when auditing anesthesia and pain management claims will be beneficial.  Stay tuned for more on the A/B CERT Task Force and how the educational products may help providers to document and bill anesthesia and pain management claims appropriately.

With best wishes,

Tony Mira
President and CEO