Medicare has disclosed the primary cause for improper payments associated with extracorporeal shock wave lithotripsy (ESWL).

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations, such as the Office of Inspector General.

As the newsletter notes, a comprehensive error rate testing (CERT) contractor conducted a special study of Healthcare Common Procedure Coding System (HCPCS) code 50590, lithotripsy (using extracorporeal shock wave) Part B claims submitted from April through June 2014 (Note: The long description for HCPCS code 50590 is Lithotripsy, extracorporeal shock wave).

The contractor found that most improper payments were due to insufficient documentation. There were no claims with medical necessity errors in the special study. When CERT reviews a claim, all lines submitted on the claim undergo complex medical review.

Insufficient documentation means that something was missing from the medical records. For example, CMS notes that the medical record was missing one or more of the following:

  • The correct date of service;
  • Medical records documenting the reason for performing the procedure;
  • Medical records documenting the results of the procedure;
  • A physician’s signature; and/or
  • A signature log or attestation for an illegible signature.

CMS provided the following two examples of improper payments due to insufficient documentation for a lithotripsy and explained what you should do if it happens to you.

1. Missing Records and a Missing Signature

A urologist billed for HCPCS 99218 (initial hospital observation evaluation and management (E&M) service) with modifier -57, and for HCPCS 50590 for a date of service in December 2013. Modifier -57 indicates an E&M service that resulted in the initial decision to perform the surgery.

The submitted documentation included an unsigned operative note for the lithotripsy procedure for the billed date of service. There were no medical records or hospital notes for the initial hospital observation E&M service. After a request for additional documentation, the CERT reviewer received a duplicate unsigned operative report; the provider did not submit a signature attestation or documentation of the E&M service.

This claim was scored as an insufficient documentation error and the Medicare Administrative Contractor (MAC) recouped the payment for both lines on the claim (HCPCS 99218 and HCPCS 50590) from the urologist.

Corrective Action: The urologist can correct the error and retain payment for the lithotripsy by submitting a completed signature attestation, and can retain payment for the E&M by submitting the medical record documentation supporting the E&M level billed. The CERT reviewer accepts late documentation even after the due date. However, CERT will not review documentation received after the due date if an appeal has been initiated.

2. Missing Signatures

A urologist billed for HCPCS 50590 and a cystoscopy with stent insertion (HCPCS 52332) for a date of service in May 2014. The submitted documentation included a pre-procedure consultation report (including history and physical examination, assessment and plan) that was not signed by the urologist. A dictated operative note for the lithotripsy procedure was submitted but it was not signed. Any note or report that is dictated or transcribed but not signed is not valid for Medicare payment.

This claim was scored as an insufficient documentation error and the MAC recouped the payment for both lines on the claim (HCPCS 50590 and HCPCS 52332) from the urologist.

Corrective Actions: Medicare requires providers of all services to sign their records. Providers should not add late signatures to the medical record but instead may submit a signed attestation, such as the one available on the CERT Provider Website. Providers should also submit an attestation if signature(s) are not legible. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry, must be for a specific date of service, and must contain sufficient information to identify the beneficiary.

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