Medicare Identifies Top Errors in Provider Documentation
By: Justin Vaughn, CPC, M.Div
Director of Compliance

It is no secret that the Federal Government regularly reviews physician claims in an effort to minimize errant billing and overt fraud.  We have alerted you to the fact that Recovery Audit Contractors (RACs) are now utilized by CMS to conduct such reviews in all 50 states, but Medicare carriers continue to conduct their own audits, as well.  Known as Comprehensive Error Rate Testing (CERT) audits, these reviews serve as a supplement to the RAC program. 

One Medicare carrier, Trailblazer, recently published a list of key deficiencies uncovered in its CERT audit of Part B claims in Texas, Oklahoma, New Mexico and Colorado.   Among other items, these deficiencies included several errors commonly found in medical record documentation, which can be summarized as follows:
Lack of Basic Information
Simple information was often missing or misidentified on the medical record, such as the patient’s name and date of service.

Inadequate Provider Identification
Handwritten signatures continue to be an issue of concern for both the Office of Inspector General (OIG) and CMS.  Providers should supply a legible identifier (consisting of at least their first initial and full last name) on the medical record to avoid possible delays in the processing of their claims.  For electronic records, electronic signatures are permitted.

Medically Unnecessary Services
For Medicare to deem a service medically reasonable and necessary, the service must be:

•    Safe and effective
•    Not experimental or investigational
•    Appropriate in duration and frequency
•    Performed in accordance with accepted standards of medical practice
•    Furnished in an appropriate setting
•    Ordered and furnished by appropriate personnel
•    Commensurate with, but not exceeding, the patient’s medical need

Insufficient E/M Documentation
Most errors revealed in the CERT audit involved inadequate documentary support of evaluation and management (E/M) services, such as:

•    Exam component not meeting the level required
•    History component not meeting the level required
•    Service not meeting the definition of a new patient
•    Service not meeting the definition of critical care

It is certainly important for our chronic pain clients to be mindful of these audit finding regarding E/M errors, but anesthesiologists should also take heed as they too will have occasion to document and submit claims for E/M services (eg, critical care, post-op pain rounds for nerve blocks, consults, canceled cases).

Though the CERT audit addressed in this alert was conducted by only one Medicare carrier and limited to only 4 states, be assured that every carrier is performing similar audits.  The trends identified in the Trailblazer review may easily translate to the kinds of errors found in other Medicare jurisdictions.  Accordingly, we at Medac urge you to document the medical record with the utmost accuracy and clarity.  

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.