WPS Medicare Part B - Quarterly CERT Error Findings Report ~ MICHIGAN ~

WPS Medicare Part B - Quarterly CERT Error Findings Report ~ MICHIGAN ~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed April 2015 through June 2015 for Michigan providers. The findings below are reported based on the type of error assessed by the CERT Contractor (e.g., insufficient documentation, incorrect coding, etc.). Insufficient Documentation - 74% of total errors Missing the physician order or clinical documentation of intent of ordering the billed cocaine or metabolite, meprobamate, methadone, creatinine; other source, ph; body fluid, and spectrophotometry for date of service (DOS) 07/18. Also missing signed and dated clinical documentation to support medical necessity for the billed labs and results. Received unsigned requisition, injection note dated 08/26 and lab report for Tetrahydrocannabinol (THC) and Phenobarbital. Requested additional documentation and received no response. Provider billed for quantitative drug levels, validity testing using urine creatinine and ph for 9/12 and submitted copy of requisition for comprehensive panel, results of multiple drug levels, and copies of office visit notes for 2013 that contain plan for urine drug testing (UDT). Note for 11/14/13 states review shows results as expected. History of recreational drug use is stated as none. Missing physician's order for each specific drug/drug class level and documentation of medical necessity for the quantitative drug level for each specific drug/drug class test. Billed laboratory tests for Methadone, Meprobamate, Mass Spectrometry, Dihydromorphinone, Dihydrocodeinone, and Cocaine. Missing the order, or intent to order, and the medical necessity to perform these tests. Received a requisition form and results only. Missing physician s order or documentation of intent of ordering the billed 5 units of Benzodiazepines, 2 units of Quantitation of Drug and 5 units of Amphetamine or Methamphetamine for date of 05/21. Documentation received initially includes laboratory report and unsigned testing requisition for saliva pain management panel. Also received notes for 8/28 and 9/30 documenting beneficiary is opiate depended secondary to chronic issues. Insufficient documentation. Missing the physician order or clinical documentation of intent of ordering the billed meprobamate, methadone, creatinine; other source, PH; body fluid, spectrophotometry, analyte, and PCP for DOS 08/21. Submitted documentation includes unsigned requisition for a custom profile, lab reports, visit notes dated 05/05-08/21, and attestation statement. Visit note dated 08/21 documents an order for CPT 80101 which is obsolete code and the replacement code for this is CPT G0431 which was billed on another claim for the same date. Missing the physician order or clinical documentation of intent of ordering the billed benzodiazepines times 5 units, quantitation of drug times 2 units, and amphetamine or methamphetamine times 5 units. Also missing signed and dated clinical documentation to support medical necessity for the tests. Received laboratory reports and unsigned lab requisition. Requested Page 1 of 6

additional documentation from the ordering provider and received a visit note that documents a chief complaint for follow-up lab work and no documentation of pain. Billed for ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day (CPT 94003). Missing: 1) a signature attestation for the progress note; 2) clinical documentation supporting ventilator management for the beneficiary by the billing provider. Received a mostly illegible progress note which is illegibly signed by the author; and respiratory flow sheets dated which are signed by the respiratory therapist. Billed: 94003 for ventilation management on 06/24 and 06/25. Missing progress notes that supports billed services. Submitted progress notes stated that the patient was on mechanical ventilation due to Acute or Chronic Respiratory Failure, 6/26 notes states, "on full vent support." No notes for vent management were submitted for billed dates of service. Insufficient information to support claim. Billed Plethysmography Diffusing Capacity Bronchodilation (CPT 94726, 94729, 94060) for 5/13. Ordered is a Pulmonary Function Test. Received a Spirometry report for 5/13 and a Plethysmography for 2012. Missing an order and a copy of the billed Plethysmography. Provider billed for 2 units of CPT 97110 (therapeutic exercises) and 2 units of CPT 97112 (neuromuscular re-education). Missing the documentation of the performance of billed services. Received a copy of the physical therapy initial evaluation, which documented 2 units of CPT 97110 and 2 units of CPT 97112 and referred to the flow sheet which was not included on initial response. Requested the flow sheet but only duplicate copy of the initial evaluation was submitted. Billed CPT 27447 LT Arthroplasty, Knee (Total Knee Arthroplasty). Submitted is an unsigned Operative report. Billed is CPT J1100 Dexamethasone 1milligram with 8 units of service. Missing procedure notes that include amount of Dexamethasone administered. Received a signed visit note that includes medical necessity, and injection procedure documenting drug. However no amount of dexamethasone was listed. Insufficient documentation to support billed services per Medicare guidelines. Billed is Denosumab 1 mg (60 units) and injection (CPT 96372, J0897) service. Missing: 1) physician s order for medication; 2) clinical documentation to support medication was administered to include dose, route of administration, site and signature of individual administering it; 3) physician s authenticated clinical documentation to support the reason/need for medication. Received Encounter summary which reads Prolia 60mg, yet missing order and documentation of administration. Missing the physician order or clinical documentation of intent of ordering the billed arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement and arthroscopy, shoulder, surgical; biceps tenodesis. Also missing signed and dated clinical documentation to support medical necessity for the surgery and billing provider signed and dated attestation statement. Received unsigned operative report only. Requested additional documentation and received duplicate documentation. Billed Ambulance service, advanced life support, emergency transport, Level 1 (ALS1-Emergency) and ground mileage. Missing: 1) A copy of the Assignment of Benefits to authorize the provider of ambulance services to bill Medicare, that was signed by the beneficiary or responsible party; or documentation to support that no other qualified person was willing or available to sign the AOB on behalf of the beneficiary. Submitted documentation included a signed and dated ambulance transport record with signatures from the receiving nurse, Emergency Medical Technician (EMT), and paramedic. Page 2 of 6

Billed A0428- non-emergent basic life support ambulance transport and A0425-ground miles (A0428/PH, A0425/PH) on date of service 03/08. Missing Assignment of Benefits, and documentation describing the medical necessity for ambulance transport. Received ambulance trip report that contains documentation describing patient transport for drug withdrawal for treatment at inpatient facility. Documentation states reason for call was "Psychiatric/Abnormal Behavior/Suicide Attempt." EMT narrative did not address reason for transport or assessment of psychiatric symptoms impacting need for transport. Submitted copy of certification form for necessity for transport that was not signed. EMT signed transport form entry for patient refusing to sign. Also submitted documentation included a patient care report which states " beneficiary awaiting transport for continued psychiatric care. Beneficiary standing in waiting room." Documentation submitted is insufficient to support these lines per Medicare guidelines. Billed for arthrocentesis, aspiration and/or injection, major joint or bursa; Hyaluronan or derivative, 1 mg (48 UOS); and ultrasonic guidance for needle placement, imaging supervision and interpretation for date of service (CPT 20610/LT, J7325), 04/08. Missing documentation to support the beneficiary failed to respond adequately to conservative non-pharmacological therapy (exercise or physical therapy, weight loss if appropriate) and a past history of treatment with analgesics and a radiological exam to support the diagnosis of osteoarthritis; significant improvement in knee pain and known improvement in functional capacity resulted from the previous series of injections which has been documented in the record; and at least six (6) months have elapsed since the prior series of injections. Claim history shows paid claim for the same services and medications billed on this claim in October of previous year. Submitted documents the beneficiary presented for a Synvisc injection; complaining of pain involving the neck, shoulders, lower back and hips with morning stiffness lasting about one hour. Clinical exam reveals no peripheral synovitis except sometimes the first carpometacarpal. "He does have small effusion present in the left knee." Documents injection under fluoroscopic guidance, after aspiration of 3 cc of clear fluid, 5 cc of Synvisc One was injected. Billed 90834/AJ psychotherapy, 45 minutes with patient and/or family member. Missing individualized treatment plan prescribed by physician, physician's supervision and evaluation, frequency and duration of service and reasonable expectation of improvement. Billed CPT 98940/AT (chiropractic manipulative treatment (CMT); spinal; 1 to 2 regions) for DOS 04/30 and 05/05. Missing: 1) Billing provider signed and dated treatment note that documents the following History (Review of chief complaint; Changes since last visit; System review if relevant); 2) Physical Exam (Exam of area of spine involved in diagnosis; Assessment of change in patient condition since last visit; Evaluation of treatment effectiveness); and 3) Need clarification of the exact location of subluxation(s) of the spine. Submitted documentation included attestation statement initial visit note dated 04/14, treatment notes from 04/14-05/05 with no chief complaints documented, no physical exam, no response to previous treatments, or symptoms. Requested additional documentation from the billing provider and received no response. Billed is CPT 98942- chiropractic manipulation treatment (CMT) 5 spinal regions billed with AT modifier - Acute treatment. Missing; 1) the initial evaluation, 2) the initial treatment plan applicable to billed date of service. Billed CPT- 99349 established patient home visit. The progress note initially submitted had the typed name of the billing provider but no handwritten or electronic signature. Subsequently received the progress note with the signature added. No attestation was submitted. Per Medicare guidelines "Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process." Page 3 of 6

Billed CPT 99222, initial hospital care. Missing a separate Evaluation and Management (E/M) note from the billing physician, to support the service as billed. Received: cardiology consult note supporting the visit was performed by a Resident that included a separate entry by the Attending physician (billing physician) indicating he saw and examined the beneficiary, confirmed essential components of history, exam, diagnosis and treatment plan; and agreed with residents documented care. There was no GC modifier submitted with this claim, therefore only the Attending note can be utilized. Insufficient documentation to support service as billed. Billed initial hospital inpatient care (CPT 99223/AI). Missing the progress note to support service. Received a brief handwritten note at the bottom of the rounds report which documents "(Beneficiary) is seen and evaluated. History and physical to be dictated." Billed smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes (CPT 99406). Beneficiary was seen for a home visit at which time the provider documents "long standing smoker; counseled on smoking cessation counseled about the bad outcome of combination smoking while on oxygen use" There is no time documented and documentation does not support more than minimal counseling which per the National Coverage Determination (NCD) guidelines is already covered at each E/M visit. Insufficient documentation. Billed Lithotripsy. Missing a valid signed operative report. The operative report submitted is missing the second page and there is no signature on page one. Requested additional documentation and no further documents were submitted. Billed ventilation assist and management (initiation of pressure or volume preset ventilators for assisted or controlled breathing); hospital inpatient/observation, each subsequent day (CPT 94003), for date of service 07/30. Missing clinical documentation to support ventilator management was performed on billed date of service. Received progress note for 07/30 that supports beneficiary presented to emergency department with respiratory failure which required intubation/mechanical ventilation and admission on 07/29. Progress note does not support management of ventilator was performed (lacks documentation of vent settings, orders regarding ventilator etc.). Also received a form which physician indicates is an order yet date of service 07/30 lacks ventilator order and practitioner signature. Documentation is insufficient to support service billed. Billed 97001(physical therapy evaluation) and 97110 (physical therapy services: therapeutic exercises, per 15 minutes), 1 unit. Missing: 1 ) Initial Evaluation /and Plan of Care certified by the treating physician and 2) re-evaluations relevant to the episode being reviewed and physician recertification's and 3)complete clinical documentation to support the billed physical therapy evaluation. Incorrect Coding - 24% of total errors Billed CPT 81001, urinalysis with micro. Recode to CPT 81003. Received copy of results and copy of office visit note that indicated intent for "urinalysis." Intent for micro not described. Billed CPT 85025, CBC with differential. Provider submitted copy of results of CBC with differential. Recode to CPT 85027. The office visit note for billed DOS indicated intent for "CBC." Intent for differential not described. Billed CPT 99205 (Comprehensive history, comprehensive exam, and high complexity medical decision making (MDM), 3/3 key components). Submitted documentation supports code change from 99205 to 99204 (Comprehensive history, comprehensive exam, and moderate MDM, 3/3 key components) for the evaluation, management and treatment of beneficiary s/p resection of a left Page 4 of 6

squamous cell carcinoma of the left ear who required aggressive cleansing of the ear with intent for follow up in four weeks for re-evaluation of the ear. Billed CPT 99215 (requires 2/3 key components; Comprehensive history, comprehensive exam, and high complexity MDM). Documentation supports recode to 99213 with expanded history, comprehensive exam, and low MDM meeting 2/3 of the required key components. Billed CPT 99222, requires 3 out of 3 key components Comprehensive history, comprehensive exam, and moderate complexity MDM. Submitted documentation supports a down code from 99222 to 99221 with Detailed History (Limited ROS), Detailed Exam using 1995 E/M guidelines, and moderate MDM. Billed CPT 99223 (initial hospital visit) that requires 3/3 components: Comprehensive History and Exam and High Complexity MDM. Documentation supports a recode to 99221 (requires 3 /3 components: Detailed /Comprehensive History and Exam and Straightforward/Low MDM. Documentation is of comprehensive history, detailed exam, and moderate MDM. Billed CPT 99223-A1 Initial Hospital Care requires 3/3 (comprehensive history and exam and high complexity MDM). Documentation submitted for the billed date supports recode to CPT 99232-A1 (Subsequent Hospital Care) with expanded problem focused (EPF) history, comprehensive exam, and moderate MDM meeting 2/3 of the required key components. Medicare regulations state a visit meeting criteria for a lower level of care than there exists an initial hospital encounter code, may be billed with a subsequent hospital encounter code. Billed CPT 99232 requires 2 of 3 key components: expanded problem focused history, expanded problem focused exam, and moderate MDM. Documentation supports a down code to CPT 99231 with problem focused history, no exam, and low complexity MDM. Billed CPT 99233 (requires 2/3 components: Detailed History, Detailed Exam and High MDM). Documentation supports down code to 99232, with EPF History, EPF Exam and Low MDM. Billed 99239 (Hospital discharge date management; more than 30 minutes). Submitted a handwritten progress note that supports a face to face encounter and a dictated discharge summary, neither of which document time spent in the provision of discharge day service(s) or support sufficient documentation that the process of performing discharge day services required greater than 30 minutes. Supports down code to 99238 (Hospital discharge day management; 30 minutes or less). Billed emergency room visit, 99285, which requires the following 3 components: Comprehensive History, Comprehensive Exam and High MDM. Documentation supports code change from 99285 to 99284 with Comprehensive History, Comprehensive Exam and Moderate MDM. Billed CPT 99306 requires 3 of 3 components (Comprehensive History and Exam and High Complexity MDM). Documentation supports code change from 99306 to 99305 as billed with Comprehensive History and Exam, and Moderate MDM per 1995 E/M guidelines. Provider billed for subsequent nursing facility visit with CPT 99310, requiring 2/3; Comprehensive History and Exam and MDM of High complexity. Submitted documentation supports CPT 99309 with EPF history, Detailed Exam, and MDM of Moderate complexity. No Documentation - 1% of total errors Billing for office visit and CERT was informed by the billing provider that beneficiary is not a patient. No documentation submitted to support service as billed. Page 5 of 6

Medically Unnecessary Service or Treatment 1% of total errors Billed for venipuncture for labs that were denied due to lack of a valid order. Not reasonable and necessary to pay for a venipuncture performed on denied laboratory tests. Based on CERT error findings for this quarter, below are educational resources that can assist in avoiding these issues in your practice. CMS Resources Ambulance CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 15 Ambulance - Necessity and Reasonableness CMS IOM, Publication 100-02, Chapter 10, section 10.2, section 20.1.2 (Beneficiary Signature Requirements), and section 30.1.1 (Ground Ambulances Services) Initial Hospital Care Service History and Physical That Is Less Than Comprehensive - CMS IOM, Publication 100-04, Chapter 12, section 30.6.9.F. National Coverage Determination (NCD) for Smoking and Tobacco-Use Cessation Counseling - CMS IOM, Publication 100-03, Chapter 1, Part 4, section 210.4 Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services - CMS IOM, Publication 100-02, Chapter 15, section 220.1.2 and section 220.3.E- Documentation Requirements for Therapy Services- Treatment Note Provider Signature Requirements - CMS IOM, Publication 100-08, Chapter 3, Section 3.3.2.4 Requirements for Ordering and Following Orders for Diagnostic Tests CMS IOM, Publication 100-02, Chapter 15, section 80.6.1 WPS Medicare Resources Local Coverage Determinations (LCDs) for: Chiropractic Services Drug Testing Home and Domiciliary Services Intra-articular Injections of Hyaluronan Polysomnography and Other Sleep Studies Psychiatry and Psychology Services Additional WPS Medicare web page resources: CERT Articles CERT Error Analysis Evaluation & Management Services (under Resources, Provider Specialties/Services) Note: Review results are based on Medicare regulations in place at the time services were rendered. Medicare providers are responsible for compliance with all current applicable Medicare coverage, coding and billing regulations upon claim submission. Page 6 of 6