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Spring 2015

Reviewing Anesthesia and Pain Management 2014 CERT Data to Improve Documentation and Revenue

Joette Derricks, CPC, CHC, CMPE, CSSGB
Vice President of Regulatory Affairs & Research, Anesthesia Business Consultants, Jackson, MI

The Comprehensive Error Rate Testing (CERT) Program is designed to measure improper payments in the Medicare Fee for Service Program (FFS), as required by the Improper Payments Information Act of 2002. The Program was initiated by Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) to achieve the agency’s mission to emphasize accountability and to pay claims appropriately. The Program produces national, contractor-specific and service-specific paid claim error rates, as well as a provider compliance error rate. The improper paid claim error rate is a measure of the extent to which the Medicare program is paying claims correctly. The provider compliance improper error rate is a measure of the extent to which providers are submitting claims correctly.

The fiscal year (FY) 2014 Medicare FFS program improper payment rate is 12.7 percent, representing $45.8 billion in improper payments, compared to the FY 2013 improper payment rate of 10.1 percent or $36.0 billion in improper payments. Table 1 outlines the improper payment rate and projected improper payment amount by claim type for FY 2014. The reporting period for this improper payment rate is July 1, 2012– June 30, 2013.

A review of the entire report Medicare Fee-for-Service 2014 Improper Payments Report including the Appendixes can help physicians and coders identify various documentation and coding errors being made by each specialty. First, let’s take a look at how the CERT Program works.

CERT Methodology

The CERT Program 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. According to HHS, the CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from the 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 the conditions 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.

For the CERT program, CMS defines “improper payment” as:

  1. No Documentation
  2. Insufficient Documentation
  3. Medical Necessity
  4. Incorrect Coding
  5. Other (Duplicate payments/no benefit category/other billing errors)

Fiscal Year 2014 CERT Program Findings

The primary causes of Part B improper payments are administrative and documentation errors (69.8 percent) due to insufficient documentation. Insufficient documentation errors occur when either the medical documentation submitted is inadequate to support payment for the services billed, or when a specific documentation element that is required as a condition of payment is missing. Other causes of improper payments are classified as authentication (no signed order) and medical necessity errors caused by medically unnecessary services and, to a lesser extent, incorrect diagnosis coding. Medical necessity errors occur when the claim review staff receives inadequate documentation to make an informed decision that the services billed were medically necessary based on Medicare coverage policies. Data shows that many improper payments resulted from claims paid for services that are clinically appropriate, if provided in less intensive settings (26 percent). Of interest is that physicians and DME suppliers contributed substantially to insufficient documentation errors and hospitals contributed substantially to medical necessity errors. Coding errors were most prevalent in physician services.

Table 2 shows the improper payment rates and provider compliance rates for anesthesia and pain management providers, along with critical care/intensivists. The critical care/intensivists data has been included since more anesthesia groups are taking over full or partial responsible for the intensive care unit.

As previously discussed, the improper payment rate is the MACs error rate, that is, based on the documentation (which may or may not have been available when the claim was paid or denied) was the claim paid or denied correctly. The provider compliance improper payment rate is the measure of whether the provider is or is not submitting claims to the MAC correctly based on the Medicare documentation guidelines per national or local coverage determinations (NCDs/LCDs). As indicated in Table 2, one-third of the critical care intensivists services reviewed were found to be improper payments by the MAC while pain management providers had a high compliance error rate.

Table 3 provides a further breakdown by selected provider type and type of error, which allows one to drill down to where the problems are occurring. The lack of sufficient documentation is the largest category of errors. Most anesthesia providers submit the anesthesia record to their coding and billing staff. So what is required or what may be missing when the independent auditor reviewed the provider’s documentation? The complete anesthesia record requires three main components. They are:

  1. A thorough evaluation of the patient by an anesthesia professional is mandatory prior to the administration of anesthesia. In addition to a review of systems and records, such an evaluation should contain personal communications; physical assessment, when indicated, and evidence that informed consent for the anesthetic has been obtained.
  2. There must be an intraoperative anesthesia record or report for each patient who receives general, regional or monitored anesthesia. Anesthesia care during the procedure is normally documented in a graphic anesthesia record, which includes a sequence of entries reflecting the anesthesia care given, the drugs and fluids administered, and the patient’s responses to the care.
  3. Post-anesthesia evaluation must be completed and documented no later than 48 hours after surgery or a procedure requiring anesthesia services. The evaluation is required any time general, regional or monitored anesthesia has been administered to the patient.

There are many specific data elements for each of the three major components of the required anesthesia documentation that must be documented in the medical record, including patient demographics, start/stop times, mode of anesthesia, signatures and medical direction requirements.

Information on the Wisconsin Physician Services (WPS) Medicare website provides an example of insufficient document for interventional pain management. WPS received notice from the CERT Contractor of errors assessed for Epidural and Transforaminal Epidural Injections due to insufficient documentation for CPT code 64483 (Injection(s), anesthetic agent and/ or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level). Included in the CERT Contactor’s comments for two different claim submissions are the following:

Case 1

Missing documentation to support use of conservative therapies prior to administration of injection on 04/14/2011, and rendering physician's signature on the provided follow-up telephone call dated 04/22/2011. Of note, this record of phone call does report the beneficiary's current pain level and is signed by the CMA.

Case 2

Provider submitted copy of physician's order and procedure report for transforaminal epidural injection and eipdurography in support of billed services for 4/29/11. However, missing is documentation of medical necessity for the procedure, as required by LCD. Provider submitted a copy of the History and Physical; however, it was not signed by the physician and the form did not include physical exam, assessment, or plan entries. A Pain Management Information form was submitted; however, the form was not signed, thus we are unable to determine that entries were those of the billing physician.

WPS cautions providers of this service to review the Epidural and Transforaminal Epidural Injections, LCD L30481 in its entirety to ensure that the provider's documentation supports the services billed.

Another example of insufficient or missing documentation was documented on another MAC’s website. This case involved the billing of HCPCS J1030- Methylprednisolone 40mg 8 units of service and J3301- Triamcinolone 10mg 8 units of service (in addition to CPT 99213, 20610 and 20551-RT/LT). The name/dose of medication administered was missing in the medical record documentation. The records submitted included an unsigned office visit note that is missing the name/dose of medication to be injected and which joints were injected with Methylprednisolone and which joints were injected with Triamcinolone acetonide. Documentation submitted for this case did not meet requirements per Medicare guidelines.

It is important to accurately document the patient’s medical record with all services performed/ordered. Documentation for injections must include the following:

  • Name of drug injected
  • Location of injection
  • Dosage of injection given
  • Route of administration
  • Signed and dated physician order to include the drug name, dosage, route of administration and duration of treatment

A CERT reviewer also found insufficient documentation to support a continued arthrocentesis procedure (CPT 20610 X3) and Methylprednisolone 80 mg injection (J1040 X3). The medical record was missing a plan of treatment to support continued need for injections as billed. This case also lacked medical necessity for ongoing extended treatment for a chronic condition that has not shown improvement in a reasonable time and treatment has become supportive rather than corrective in nature and is then considered maintenance treatment. Per claim history, arthrocentesis procedure (X3) and Methylprednisolone 80 mg injection (X3) billed every three months since 2009 and additional submitted documentation indicates ongoing injections prior to 2009.

Pain management physicians need to understand in treating chronic pain that maintenance services are not considered medically reasonable or necessary under Medicare. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the treatment is then considered maintenance therapy. Upon medical review, maintenance treatment will be denied.

An example of incorrect coding was documented in a CERT review for CPT 99291, Critical Care (first 30-74 minutes). The documentation described a beneficiary with a history of falls. There was no location of any injury documented. The medical record noted that the beneficiary complained of feeling weak for a few days with low blood pressure and a rapid pulse. The submitted documentation was presented in the format of a regular Evaluation and Management service (E/M) (e.g., history, including HPI, ROS and PFSH; exam and medical decision-making). An attached rhythm strip showed "SVT vs aflutter at 158" non-specific changes. The provider documented 15 minutes for the history and physical, 15 minutes with orders, 10 minutes to check and evaluate lab and x-ray findings etc. No minutes were documented for the procedure time. A total of 45 minutes were documented as critical care time; however, the documentation submitted did not support that at the time the service was rendered, the beneficiary was at risk of imminent deterioration and required the constant or near constant attention of the billing physician. The CERT reviewer changed the billed code to CPT 99285 per 1997 E/M guidelines as the medical record did support a comprehensive history and exam and moderate/high complexity medical decision-making.

While Table 3 reflects a claim count of only 62 claims from critical care intensivists, the total claim count for critical care, first hour (CPT 99291) was 315 services indicating that many critical care services are reported by other specialties. The CERT review found that 29 percent were overpayments.

Anesthesiologists who provide critical care services need to ensure that all the criteria for critical care services are met in order to be considered for Medicare payment. Critical care is defined as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

Providing medical care to a critically ill, injured or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements. If you bill these services to Medicare it is important to be aware of these requirements to avoid claim payment denials or reductions.

The MACs closely monitor CERT review findings, and they may request overpayments or open a provider or service specific audit based on the CERT review. In addition, the Recovery Auditor Contractors (RACs) also use the CERT findings as support for pursuing specific service audits. It is important that all Medicare providers understand general Medicare coverage criteria to avoid the potential for additional claim reviews and costly recoupments.

The HHS improper payment rate target for 2014 was 8.3 percent. As a result of not meeting the target, providers can expect more reviews, including moving the Medicare FFS RACs to more prepayment reviews to prevent improper payments and away from the pay-and-chase model. In addition, HHS is continuing to build the Healthcare Fraud Prevention Partnership (HFPP), which is a publicprivate partnership to improve detection and prevention of healthcare fraud, waste and abuse. The HFPP is a collaboration of private and government payers using data exchanges, analytical tools, and anti-fraud best practices. Providers should review past and current CERT findings to ensure they are reporting similar services correctly.


Joette Derricks, CPC, CHC, CMPE, CSSGB serves as Vice President of Regulatory Affairs and Research for ABC. She has 30+ years of healthcare financial management and business experience. She is a member of MGMA, HCCA, AAPC and other associations and a regular speaker at practice management conferences. Ms. Derricks can be reached at