Medicare Benefit Policy Manual

CHAPTERS 1 -4-6-12Chapters Recently Changed

Medicare Benefit Policy Manual

Chapter 1 - Inpatient Hospital Services

Covered Under Part A 1 – Definition of Inpatient Hospital Services 10 - Covered Inpatient Hospital Services

Covered Under Part A

(Rev. 119, 01-15-10)

Medicare Claims Processing Manual

Chapter 4 - Part B Hospital (Including

Inpatient Hospital Part B and OPPS)

(Rev. 1882, 12-21-09)

Medicare Benefit Policy Manual

Chapter 6 - Hospital Services Covered Under Part B

Transmittals for Chapter 6 Crosswalk to Old Manuals 10 - Medical and Other Health Services Furnished to

Inpatients of Participating Hospitals 20 - Outpatient Hospital Services 20.1 - Limitation on Coverage of Certain Services

Furnished to Hospital Outpatients

(Rev. 116, 12-11-09)

Medicare Claims Processing Manual

Chapter 12 - Physicians/Nonphysician Practitioners

(Rev. 1843, 10-30-09) (Rev. 1859, 11-20-09) (Rev. 1875, 12-14-09) (Rev. 1881, 12-18-09) 10 - General 20 - Medicare Physicians Fee Schedule (MPFS) 20.1 -

(Rev. 1881, 12-18-09)

CMS Tightens Documentation and

Signature RequirementsImpact of More Stringent Review

Criteria

In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment.

Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

 

Records from the treating physician not submitted or incomplete

In the past, CERT would consider an unsigned requisition or physicians' signatures on test results.

Now, CERT requires evidence of the treating physician's intent to order tests, including signed orders and/or progress notes.

 

Missing evidence of the treating physician's intent to order diagnostic tests

Again, in the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment.

Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

 

Medical records from the treating physician did not substantiate what was billed

 

In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures.

Now, CERT disallows entries if a signature is missing or illegible.

 

Missing or illegible signatures on medical record documentation

CMS has instructed CERT contractors to follow the letter of the law in determining whether a claim has been billed properly and if there is sufficient documentation present to support the need for services. Thus, each claim must stand alone and be supported by documentation clearly showing the intent of the ordering physician and the reasons for ordering the service(s) for that episode of care, with orders that are complete and signed.

CERT Contractors Advised

Further details related to signatures were published in Transmittal 327 of the Medicare Program Integrity Manual (100-08), released on March 16, 2010. The signature guidelines apply to reviews conducted by Medicare Administrative Contractors (MACs), CERT Contractors and Recovery Audit Contractors (RACs).

 

Transmittal 327

Medicare requires that services provided or ordered be authenticated by the author. The method used for authentication may be a handwritten or electronic signature. Rubber-stamp signatures are not acceptable.

  Exceptions are made for certifications of terminal illness

for hospice care and orders for clinical diagnostic tests. However, if there is an unsigned order for a clinical diagnostic test, there must be documentation by the physician, such as a progress note, that shows that the physician intended for the test to be performed. This documentation must be authenticated.

No Rubber Stamping

CMS states that providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead use the signature authentication process. This process requires the author of the order to sign an attestation that he/she is the originator of the order, and does not allow for anyone but the ordering/treating physician to make the attestation. While there is currently no specified format or language for the attestation, a suggestion is included in the transmittal.

Signature authentication process

Signatures must be complete and legible. If a signature is illegible, there must be a typed or printed name next to the signature. Initials are not acceptable as signatures without further documentation (attestation, signature log, typed or printed name next to the initials, etc.)

 

To assess the impact of these two documents, providers should conduct their own review of order signatures to see if they meet these new requirements. At the same time, the documentation supporting the services provided should be reviewed to determine if it provides all the information necessary to support medical necessity.

 

Here is a simple yet common example of an excisional debridement claim that a RAC determined to be incorrectly coded:

  A physician wrote in the medical record that "debridement

was performed."  Procedure code 86.22 was assigned by a coder.

A complex review was conducted and the RAC determined that the procedure should have been coded 86.28, because there was no reference to "excisional" and no indication that it was in fact the physician who performed the procedure.

excisional debridement

Today, however, a RAC might not make this same decision. According to the rules issued by Coding Clinic in the fourth quarter of 1998, the denial decision was correct, but those rules were superseded by a slightly different set of regulations issued in the second quarter of 2000. By then, CMS decided that excisional debridement could be performed by a nurse, therapist, physician assistant, or a physician.

  Nevertheless, the physician still must document

"excisional debridement" in the record, or it won't matter.

Remember: not documented = not done.

Remember: not documented =

not done.

Also, it is important for physicians to know that simply stating "excisional debridement was performed" is simply not enough detail. Why? Because the definition (in ICD-9-CM Volume 3) of procedure code 86.22 states that it must include "removal by excision of devitalized tissue, slough or necrosis." This can be done by a sharp instrument, or even a laser, however the service must be described further as a cutting away of tissue, not simply the removal or scraping away of loose skin.

 

Simply not enough detail

In addition, there are some things specifically excluded by the definition: it cannot include debridement of abdominal wall, bone, muscle or nails, nor non-excisional debridements, open fracture debridements, or pedicle or flap graft debridements.

It may seem like CMS is splitting hairs here: after all, the care is being given and we're not even talking about medical necessity, so what's the big deal? What difference does it make? To a patient, perhaps none. To a facility, however, it's HUGE.

  Without going into details here, there is a

difference that could be as much as $6,600 for a single claim .

Splitting Hairs; Huge Impact

Today, President Obama signed into law the “Continuing Extension Act of 2010” extending the freeze on the Medicare Physician Fee Schedule through May 31, 2010. This temporary postponement prevents physicians from suffering the 21.5% physician cut in Medicare reimbursements that had been in effect since April 1.  Effective immediately, CMS will instruct its contractors to submit claims that have been held since April 1 and later for processing and payment.  

Extension Bill Signed

Congress must continually be encouraged to address the SGR issue to eliminate the ongoing threat of the 21.5% reduction in reimbursement for services to Medicare patients. 

Physicians should take the same preventative measures that facilities take against RACs. By making sure the billing is clean, the documentation is in order, and that the bill matches the documentation, this strategy should benefit physicians and prevent audits.

All Provider Types With Internal Medicine 9.4% $48,653,191

1.4% Family Practice 8.7% $21,299,713 1.9% Cardiology 5.7% $21,138,857 1.7% Orthopedic Surgery 8.4% $12,664,058

3.7% Pulmonary Disease 9.9% $9,286,467

4.8% Nephrology 11.4% $9,025,301 7.5% Emergency Medicine 5.8% $7,090,258

2.0%

Projected Improper Payments Standard Error

General Surgery 4.8% $5,531,184 2.7% Ophthalmology 2.5% $4,891,194 2.1% Urology 3.1% $4,583,069 2.0% Diagnostic Radiology 2.0% $4,075,457

1.6% Podiatry 7.2% $4,057,267 2.7% Hematology/Oncology 1.1% $3,311,955

0.8% Gastroenterology 2.8% $2,303,952

2.1% Anesthesiology 2.1% $1,245,543 1.5% Clinical Laboratory 0.7% $1,089,499

0.4%

All Provider Types 5.1% $210,566,867

Thank You