Insufficient documentation is behind most improper payments, according to the government agencies responsible for policing Medicare program claims. Those same agencies, which include programs operated by the U.S. Centers for Medicare and Medicaid Services (CMS), repeatedly advise healthcare providers that they can avoid errors by complying with documentation requirements, including those in local coverage determinations (LCDs).
The alternative viewpoint, expressed by many radiologists, is that payors are averse to issuing reimbursement. However, what is much closer to the truth is that payors are averse to issuing reimbursement when available documentation does not prove conclusively that the service was medically necessary. There is no shortage of audit reports sending this message to providers, and it's far time that they begin to listen.
Codes reviewed
Earlier this year, via its July 2014 Medicare Quarterly Provider Compliance newsletter, CMS summarized documentation issues related to vertebroplasty and kyphoplasty that auditors uncovered during a Comprehensive Error Rate Testing (CERT) program review.
Jeff Majchrzak of Panacea Healthcare Solutions.Interventional radiologists often perform these procedures, which until January 1, 2015,1 are identified by the following codes:
- 22520: Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body, unilateral or bilateral injection; thoracic
- 22521: Lumbar
- 22522: Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)
- 22523: Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); thoracic
- 22524: Lumbar
- 22525: Each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)
Also until January 1, 2015,1 the codes below are used to identify the related imaging guidance:
- 72291: Radiological supervision and interpretation (S&I), percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance
- 72292: Under CT guidance
Results of CERT reviews
Per CMS guidelines, the mission of the CERT contractors is to calculate the Medicare fee-for-service (FFS) improper payment rate. They evaluate a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.
In this specific audit, the CERT program reviewers conducted a special study of CPT codes 22520-22524 and found that insufficient documentation caused approximately 97% of the improper payments on claims submitted by hospitals, physicians, and other providers. Missing pieces included the following:
- No physician signature in the procedure note
- No documentation of the patient's:
- Clinical condition or response to conservative care
- Relevant medical history
- Pertinent physical examination
- Diagnosis
- Results of pertinent diagnostic tests and/or procedures
- Noncompliance with LCD requirements, which define the circumstances demonstrating medical necessity
Kyphoplasty example
As an example, a physician billed for a fluoroscopically guided thoracic percutaneous kyphoplasty (for the primary procedure and one additional thoracic vertebral body) with surgical codes 22523 and 22525 and the appropriate guidance code of 72291 twice, once per level treated.2
The medical records reviewed did not include detailed clinical documentation or office notes, as required by the LCD. They also did not include the beneficiary's symptoms, functional level, severity of pain, or previous treatments.
The submitted documentation did include the following:
- Operative report
- Physician's orders
- Cursory history
- Physical exam performed on the procedure date
- CT report dated less than two weeks prior to the procedure
- X-ray films
When the CERT reviewer requested additional documentation from the billing provider, it received duplicate documentation, an MRI report dated four days prior to the procedure, and a signed and dated surgical log.
However, the submitted documentation did not support the LCD requirements. The CERT reviewer cited an insufficient documentation error, and the Medicare administrative contractor (MAC) recouped the payment from the provider.
Vertebroplasty example
In a second example, a physician billed for a CT-guided thoracic percutaneous vertebroplasty (for the primary procedure and one additional thoracic vertebral body) with surgical codes 22520 and 22522 and S&I code 72292 twice, once for each separate level treated.2
An office note dated three weeks prior to the procedure stated the following: "The course has been gradually improving (especially last two weeks)" and "her pain has improved a great deal in the last two weeks." A procedure note was received, but there was no further documentation to support the reason for surgery.
Additional documentation was requested, and the physician submitted an office note and an x-ray report that were dated more than three months prior to the procedure. There was no documentation supporting the reason for the procedure. The x-ray report was of the lumbar spine (although the procedure was on the thoracic spine) and documented "no compression deformity seen."
This CERT auditor scored the claim as an insufficient documentation error and the MAC recouped the payment from the provider.
Lessons to learn
To stay in compliance with the medical-necessity requirements for the above -- and all -- procedures, radiologists must be able to supply, when requested, complete clinical documentation for the procedures they perform. Usually, this requires requesting additional items from the referring physicians.
Unfortunately, many radiologists and their staff are unwilling to go the extra step to get this documentation. The claim denials and subsequent lack of reimbursement that will result without complete documentation are preventable by ensuring that the required documentation -- the information that proves medical necessary -- is included in the medical record.
Notes
- These codes are valid only until December 31, 2014. Beginning January 1, 2015, they will be deleted from the CPT.
- The CERT study did not include imaging guidance codes. The author of this article provided the code assignments for these examples.
Jeff Majchrzak is vice president of clinical consulting services, radiology, for Panacea Healthcare Solutions. In his role as consultant, he conducts CPT coding assessments for both hospitals and physicians, evaluates administrative policies and procedures, and helps develop quality assurance programs to ensure complete and compliant coding and billing. Jeff trains both radiology and cardiology staff (on both technical and professional billing issues) in correct coding practices. Jeff contributes to numerous publications by MedLearn Publishing (a division of Panacea) and is a sought-after national speaker on coding and reimbursement for radiology, interventional radiology, nuclear medicine, and cardiology. Jeff can be reached at [email protected], or visit Panacea Healthcare Solutions at www.panaceahealthsolutions.com.
