Medical Billing and Coding Healthcare Blog

Medicare has determined that the majority of the improper payments for end stage renal disease (ESRD)-related services were due to insufficient documentation.

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers to avoid common billing errors and other erroneous activities when dealing with the Medicare Program.

The most common causes of improper payments for ESRD-related services was determined through a Comprehensive Error Rate Testing (CERT) contractor conducting a special study of the following HCPCS codes for ESRD-related services:

  • 90960 — ESRD-related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month
  • 90961 — ESRD-related services monthly, for patients 20 years of age and older; with 2-3 face-to-face visits by a physician or other qualified health care professional per month

The study determined that approximately one-third of the payments for ESRD-related services were improper payments. The majority of the improper payments were due to insufficient documentation.

The rest of the improper payments were due to incorrect coding or no documentation submitted.

Insufficient Documentation Causes Most Improper Payments

Insufficient documentation means that something was missing from the medical records. For example, there was:

  • No physician's signature on an order; or
  • No documentation of the provider's face-to-face encounter(s).

Examples of Improper Payments for ESRD Services
Insufficient Documentation for ESRD Services
A nephrologist billed for HCPCS 90960 for the month of June 2013. The documentation submitted included inpatient progress notes for three dates in July during a one week span of time. Hemodialysis orders were submitted for those three dates. The CERT reviewer requested additional documentation from the treating physician and received an attestation to his signature on the progress notes previously submitted, but the documentation did not support the billed code which is for four or more face-to-face visits. This claim was scored as an insufficient documentation error and the Medicare Administrative Contractor (MAC) recouped the payment for the ESRD-related services from the provider.

Insufficient Documentation for ESRD Services
A nephrologist billed for HCPCS 90960 for the month of June 2013. The submitted documentation included hemodialysis treatment notes dated 06/03/2013 through 06/28/2013 that were signed by the dialysis nurse. There was no clinical documentation to support face-to-face physician visits for this beneficiary during the month of June 2013; specifically, there was no documentation of assessment/examination or plan for the month of June 2013. The CERT reviewer requested additional documentation from the billing provider and received a signature attestation (see the CERT provider website for an example of a signature attestation). This claim was scored as an insufficient documentation error and the MAC recouped the payment from the provider.

Incorrect Coding for ESRD Services
A nephrologist billed for HCPCS 90960 for the month of June 2013. The submitted documentation included one physician's note for date of service 06/10/2013, lab results, dialysis treatment notes for the month of June 2013, orders and visit rosters, which documented the dates of dialysis services (June 3, 7, 10, 14). However, there was no documentation of face-to-face encounters with the nephrologist other than the physician's note dated 06/10/2013. The CERT reviewer determined that the documentation supported a code change from 90960 to 90962 (ESRD-related services monthly, for patients 20 years of age and older; with 1 face-to-face visit by a physician or other qualified health care professional per month). This claim was scored as an incorrect coding error; the MAC adjusted the claim and recouped part of the payment from the provider.

No Documentation for ESRD Services
For the month of June 2013, there was a nephrologist billing for HCPCS 90961. No documentation was submitted in response to a request for the medical records. The CERT reviewer made a second request for documentation from the billing provider and received a note stating "this service was billed in error; please remove from patient's records. Refund will be sent." The claim was canceled two months after the date it was sampled by the CERT program. This claim was scored as a "no documentation" error because the CERT program measures improper payments even if providers voluntarily refund overpayments.

Nephrology billing is highly complex. It requires dedicated resources to manage, understand and navigate ever-changing guidelines and insurance requirements, which is why more nephrology practices are outsourcing their billing to PGM Billing. PGM's team of certified medical coders and billing experts will manage all aspects of your billing to help ensure you receive proper, timely compensation for services provided.

Congress has adopted legislation that will eliminate the Centers for Medicare & Medicaid Services' (CMS) use of the physician payment formula known as the sustainable growth rate (SGR) formula.

The Medicare Access and CHIP Reauthorization Act of 2015 received 392 votes in the House and 92 votes in the Senate. According to a White House blog post, this law strengthens Medicare, extends the Children's Health Insurance Program (CHIP), and makes numerous other improvements to the healthcare system.

Doctors who care for Medicare patients will no longer have to worry about the possibility of an arbitrary cut in their pay. Medicare beneficiaries won't have to worry that the SGR formula will jeopardize their ability to see a provider.

The new law helps orient Medicare's physician payment system toward rewarding the quality of the care physicians provide a patient rather than just the number of tests and procedures they do for a patient. The Actuaries at CMS estimate that the percent of Medicare physician payments in payment models that encourage higher quality care would more than double in four years, from 25% this year to 60% in 2019 as a result of this law. In addition, the law increases Medicare's ability to share privacy-protected data with clinicians.

The law also extends CHIP, which has provided health coverage to over eight million children. The law also continues the Maternal, Infant, and Early Childhood Home Visiting Programs, protects access to care through Community Health Centers, extends the National Health Service Corps and Teaching Health Center funding and makes permanent a program to assist low-income individuals with their Medicare premiums.

According to an AMA Viewpoints post by American Medical Association President Robert M. Wah, MD, here are five benefits of the passing of the bipartisan legislation:

  • Medicare and TRICARE patients will no longer face constant uncertainty over whether they might lose their access to care.
  • Physicians' practices will be more sustainable.
  • The path will be cleared for new models of care.
  • Health outcomes will be improved in the clinic setting and the community.
  • Physicians in training will be taught how to practice in the new health care environment.

President Barack Obama signed the Medicare Access and CHIP Reauthorization Act on April 16.

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