Bill it
Right the First Time
19 October 2017
This blog is designed to
provide education on how to avoid common billing errors and other erroneous
activities when dealing with the Medicare Fee-For-Service (FFS) Program and/or
other carriers.
Provider Types Affected: Physicians
Background: The rotator cuff is a frequent location of
shoulder pain which can result in weakness and shoulder instability.
Arthroscopic rotator cuff repair is a procedure to repair tears of the rotator
cuff. Description of Special Study:
The CERT review contractor conducted a special study of
claims with lines for arthroscopic rotator cuff repair procedures billed with
Healthcare Common Procedure Coding System (HCPCS) code 29827 (arthroscopy,
shoulder, surgical; with rotator cuff repair) submitted from January through
March 2016.
Finding: Insufficient Documentation Causes Most Improper
Payments Most improper payments for HCPCS code 29827 in this special study were
due to insufficient documentation errors. Insufficient documentation means
something was missing from the medical records. For example, claims with
insufficient documentation lacked one or more of:
• Supporting documentation for the medical necessity of
the procedure
• Procedure note
• Physician’s signature, or signature attestation, on a
procedure note or diagnostic report
The CERT review also concluded on other services for the
same period:
Improper Payments due to Insufficient Documentation -
Missing documentation to support medical necessity
Sample of Claims Reviwed:
#1
The submitted records were missing the provider’s order
for the B-12 injection and documentation supporting the medical necessity of
the medication. The CERT review contractor scored this claim as an insufficient
documentation error and the MAC recovered the payment from the provider
#2
A provider billed an APC payment line for HCPCS code
96372 (Therapeutic, prophylactic, or diagnostic injection; subcutaneous or
intramuscular) with APC code 00437 (Level II Drug Administration). The service
of HCPCS code J3420 (Vitamin B-12 injection) was a packaged service under APC
code 00437. The provider submitted the following:
• Medication administration record
And additional request for documentation returned no
documentation.
The submitted records were missing the provider’s order
for the B-12 injection and documentation supporting the medical necessity of
the medication. The CERT review contractor scored this claim as an insufficient
documentation error and the MAC recovered the payment from the provider.
Providers and/or
Suppliers are encouraged to be familiar with the details of Medicare Coverage
Policy , Medicaid Coverage Policy and Commercial Health Insurance Coverage .
Providers and/or Suppliers should carefully review the medical record documentation
to assure proper use of codes and medical necessity.
Avoid the request to Recover payments.
For more information regarding this blog or to inquire
about our Consulting Services , please contact us:
Paul
G. Silverio-Benet
305-975-1171
Our Services:
· HEDIS Compliance
· MACRA-MIPS Compliance
· Coding & Reimbursement
· Local/State/Federal Compliance
· Medicare and Medicaid Audits
· Practice Administrator
· Provider Contracting
· Provider Credentialing
· Practice Analysis
· HCC- MRA Compliance
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