Comprehensive Error Rate Testing
Common CERT Errors - Chiropractic
In recent Communiqué articles, we have been focusing on CERT errors received by specific provider specialties. This will allow us to identify documentation needs and inadequacies and the impact that these specialties have on our CERT error rate. Our focus this month is on Chiropractic services.
Analysis of our current CERT error findings show that the most common errors assessed for this specialty involve insufficient documentation and medically unnecessary services. Below is a sample of the services involved, and the corresponding CERT reviewer's comments.
Insufficient Documentation
98940- Chiropractic manipulative treatment (CMT); one to two regions
CERT Comments:
- Please submit documentation to support the HCPCS/services 98940 billed. In addition, please submit all related medical records/documentation for the HCPCS/services for the period covering the preceding 6 months prior to the Date of Service (DOS) 06/22/2005 for this claim, if the services in those 6 months are associated with the same condition. Submitted information should also include a plan of care to support chiropractic services rendered for this course of treatment. Include for DOS the patient c/o, response to treatment, and on going plan of care. Noted patient name is missing from the submitted documentation. Please verify patient name for this DOS. Received additional information from Tech Stop, but per SSA 1833e and LCD Chiropractic Services #CHIRO-001 V12 (Rev. eff. 11/02/2004), fails LCD requirements for subsequent visit. There is no review of c/c, exam, or evaluation of treatment effectiveness.
98941- Chiropractic manipulative treatment (CMT); spinal, three to four regions
CERT Comments:
- Need copy of subsequent visit office notes for dates of service 04/11/2005 and 04/13/2005 including required periodic history update, physical exam for dates billed and assessment of change in patient condition since last visit. Per LCD - Chiropractic Services #CHIRO-001 V15 (Rev. Eff. 11/02/2004) which requires subsequent visits to have: 1) history of chief complaint; changes since last visit and system review if relevant and 2) physical exam with exam of area of spin involved in diagnosis; assessment of change in patient condition since last visit and evaluation of treatment effectiveness
- Need to resubmit legible copy of progress note for bill DOS 06/03/2005. Unable to read physician's handwriting on previous note submitted. Also, no patient label is found on any of the progress notes. Submitted information should also include a plan of care to support chiropractic services rendered for this course of treatment. No additional documentation submitted from follow-up request.
- Please submit documentation to support the HCPCS/services billed on this claim as shown on the Medical records/Documentation Pull List. In addition, please submit all related medical records/documentation for the HCPCS/services for the period covering the preceding 6 months prior to the Date of Service (04/11/2005) for this claim, if the services in those 6 months are associated with the same condition. Submitted information should also include a plan of care to support chiropractic services rendered for this course of treatment. Per CMS Manual System Pub. 100-2, Chapter 15, §240 and LCD #CHIRO-001 V12 (Rev. Eff. 11/02/2004). Documentation submitted does not include required treatment plan, initial evaluation, or documentation to support an acute episode. Submitted progress notes state objective diagnosis with note made of area treated and "Return 1 month". Review of claims history file indicates initial paid chiropractic claim 02/07/05 with same diagnosis submitted.
98942- Chiropractic manipulative treatment (CMT); spinal, five regions
CERT Comments:
- Need Progress and Treatment notes submitted for 08/08/05. Submitted information should also include a plan of care to support chiropractic services rendered for this course of treatment including date of service 08/08/2005-08/10/2005. Received submitted Chiropractic examination for 07/11/2005. Received treatment page documentation with no beneficiary's identity for date of service 08/10/2005. Missing progress and treatment notes for billed date of service
Medically Unnecessary Services
98940 - Chiropractic manipulative treatment (CMT); one to two regions
CERT Comments:
- Services not medically necessary. Documentation submitted supports this is monthly maintenance therapy. The claims history file verifies monthly billing for these services from 05/04/2005-12/27/2005.
- Services not medically necessary. Documentation submitted supports this is maintenance therapy every two weeks with no improvement in condition
- Need documentation to support area of subluxation by physical exam, (i.e. Range of motion abnormality; asymmetry/misalignment; tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament etc.) for DOS. Submitted progress note states, "occasional sharp pain in lower back and hips." Insufficient to define subluxation per LCD requirements. Assessment supports pain, intensity and location only. Documentation fails to support medical necessity per LCD requirements.
Insufficient documentation of services and services determined to be medically unnecessary continue to be areas of concern due to their impact on our CERT error rate. As a result of our follow-up calls to obtain outstanding CERT documentation from providers, we have often found that the patient's file is missing the documentation to support all services billed or that several contacts are required to obtain all requested documentation.
Please be aware that services billed to Medicare Part B must be documented as billed in the medical records. Without adequate documentation, the services will be considered non-rendered, not provided at the level at which they were billed, or not medically necessary.
If your facility receives a CERT request for medical records, please review the request in detail to ensure that the required documentation is present, prior to forwarding to the CERT contractor. This includes all care plans, physician orders, patient history and any other documentation requested to support the medical necessity of the billed services. It is also important to verify that the records are legible and that they clearly identify the patient.
If you have questions regarding what documentation is needed to fully comply with the CERT record request, you may contact the CERT Contractor at the number indicated on the request letter.
(Dated 03/20/06)
