WPS Commitment to Error Rate Reductions
Based upon the Government Performance and Results Act of 1993, which sets performance measurements for Federal agencies, CMS has developed a very stringent plan outlined to reduce national claims paid error rates. CMS is working closely with all Carriers to implement aggressive efforts to lower the national error rate. CMS has published goals in the Improper Medicare Fee-for-Service Payments Report FY 2004, which outlines where Carriers must reduce error rates. In many of these areas, CMS wants to see the error rate decrease by as much as 20% by FY 2006.
CMS requires Carriers to implement local efforts to lower these error rates by developing plans that address the cause of the errors, the steps they are taking to fix the problems, and other recommendations that will ultimately lower the error rates. Claim error rates have already been accumulated for the May 2005 Error Rate Report, which leaves Carriers with a very tight time frame to reduce these identified error rate categories by 20%.
In order to meet CMS' error rate reduction expectations, WPS is working hard to identify problem areas contributing most significantly to our jurisdiction's error rate and further develop proactive educational plans to address these identified areas. We are hopeful that these educational efforts will improve the identified areas by reinforcing the importance of sending adequate documentation. If our intensified efforts do not result in a significant reduction in those areas identified as a problem in our jurisdiction, it may be necessary to perform pre-payment reviews and/or onsite visits to providers. Evaluation and Management (E/M) services will be a major area of focus due to the high jurisdictional and national error rates associated with these codes.
On a national level, among all carriers, the most significant type of error in FY 2004 was insufficient documentation of services. Insufficient documentation of services accounted for 43.7% ($8.7B) of the net errors. Insufficient documentation means that the provider did not include pertinent patient fact (i.e., the patients overall condition, diagnosis, and extent of service performed) in the medical record documentation.
Listed below are the top five services for insufficient documentation errors, based on projected improper payment amounts, for all carriers from the November 2004 Report.
Service Billed to Carriers Paid Claims
Error Rate Projected Improper
Payments
Subsequent Hospital Care (99233) 21.2% $234,803,355
Subsequent Hospital Care (99231) 24.3% $170,923,298
Critical Care, First hour (99291) 20.9% $134,657,112
Hemodialysis, one evaluation (90935) 24.3% $36,749,272
Therapeutic Activities (97530) 23.5% $34,533,117
WPS findings from the November 2004 CERT report show that no documentation and insufficient documentation still make up the majority of our CERT errors as a Carrier. Insufficient documentation accounted for 3.4% of our total error rate of 11.1% for our four-state jurisdiction.
Due to the number of claims involved, evaluation and management services continue to be an area of concern related to these errors. Below are examples of comments WPS has received from the CERT reviewers for "insufficient documentation" errors for evaluation and management services.
Hospital visits - subsequent
- This is the third copy of the consultation submitted by the provider. No copy of the documentation for subsequent hospital care billed.
- Date of service on records received is several days later than date billed.
- Submitted documentation consists of an emergency room visit by a different provider.
- Submitted documentation lacks signature from provider for date billed.
- Submitted documentation contained the admission and discharge form, not the progress note.
Office visits - established
- Need documentation of E/M service provided in addition to injection billed. Code 99211 should not be used if documentation does not support that an E/M service was performed and was necessary. There is no evidence that the beneficiary presented on the billed date of service for anything but the injection.
- A provider other than the billing provider signed copy of physician note.
- There is no documentation of physical exam, medical decision making, or a physician signature.
- Submitted documentation includes orders for the diagnostic report. Missing the notes for the office visit.
- Office notes submitted do not contain identification features such as a patient name or date of birth.
Consultations
- Missing inpatient consultation not to support service billed. Only EKG and physician orders were sent.
- The documentation submitted only contained facility internal financial documents.
As part of their efforts to decrease the insufficient documentation problem, CMS has recently extended the time providers have to respond to record requests from 55 to 90 days. It is anticipated that allowing extra time to prepare these responses will result in more complete submissions. In addition, CMS is working with Carriers to obtain accurate provider addresses, and improve the process of requesting and receiving medical records. Although these changes are expected to have a positive impact on documentation issues, ultimately it is the responsibility of each provider to furnish the requested medical documentation that supports the services billed. It is extremely important to ensure that you return the requested information within the timeframe given, and that you include all necessary documentation to support the medical necessity and level of service(s) that you billed to the Medicare Part B program.
We will be publishing future articles in our Communiqué concerning our CERT errors and/or improvements. If you would like to read the Improper Medicare Fee-for-Service Payments Report FY 2004 Report, you may do so at the following link; http://coverage.cms.fu.com/certpublic/2004-Medicare-Error-Rate-Long-Report-v2.pdf (pdf - 67 pages; 1MB)
