Summary of Common Errors Identified by the Comprehensive Error Rate Testing (CERT) Program
The Comprehensive Error Rate Testing (CERT) Program was implemented by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claims processing by Medicare contractors, like Cahaba. Contractors are then notified by CERT of the errors and findings.
Cahaba uses this information to conduct data analysis and determine the magnitude of the error and/or finding. This data analysis aids us in the implementation of corrective actions, such as probe reviews and provider education. Cahaba reports these corrective action activities to the CMS in an Error Rate Reduction Plan (ERRP).
Select your provider type listed below to review examples of Cahaba's errors identified by CERT. We encourage all providers to review this listing to educate you on common errors.The intent in providing this information is to prompt you to conduct an internal analysis of Medicare billing and reduce future denials by Medicare.
Hospital / Critical Access Hospital (CAH) Identified Errors
| Provider Type | TOB | Error Identified by CERT |
|---|---|---|
| Hospital Outpatient NEW |
13X | Provider billed HCPCS code 83519 - Immunoassay, analyte, quantitative; by radiopharmaceutical technique. Documentation supported correct HCPCS code was 83880 - Natriuretic peptide. HCPCS code was changed by CERT to 83880. |
| Hospital Outpatient NEW |
13X | Provider billed HCPCS code 62311 - epidural steroid injection. The claim also included HCPCS code 76000 - Fluoroscopy, with modifier 59 to indicate a distinct procedural service for the same DOS. The documentation supported that fluoroscopy was utilized to locate the L4 – L5 interspace in order to administer an epidural steroid injection. The correct code should have been HCPCS code 76005 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (Epidural, transforaminal epidural, subarachnoid, paravertebral facet Joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction. HCPCS code 76005 is packaged under OPPS with payment included with the APC for 62311. |
| Hospital Outpatient NEW |
13X | Provider billed more than one unit of HCPCS Code 94664 - Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device. Only one unit of this HCPCS code should be billed per line or date of service. |
| Hospital Outpatient NEW |
13X | Provider billed HCPCS code 64479 - Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level. A pain management note indicated L4 and L5 were blocked. The provider indicated the correct HCPCS code should have been 64483 - injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level. Also, HCPCS code 64484 - injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level, should have been billed rather than HCPCS code 64480 - injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level. |
| Hospital Outpatient NEW |
13X | Provider billed HCPCS code 50398 - Bilateral ureterostomy tube exchange, with a modifier 50. The provider billed this same CPT code on a different line. Modifier 50 is used to report bilateral procedures that are performed at the same operative session as a single line item. Do not use modifiers RT and LT when modifier 50 applies. Do not submit two line items to report a bilateral procedure using modifier 50. Per the 2007 CPT Expert, when a modifier 50 is submitted, Medicare allows payment for both procedures at 150 percent of the usual amount for one procedure. The modifier does not apply to bilateral procedures inclusive to one code. |
| Hospital Other (Diagnostic) NEW |
14X | HCPCS Code 87220 - Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites, scabies. The provider stated they had performed a fungal stain on sputum specimens, which is HCPCS code 87205. The provider reported that due to an error in their coding software, the wrong code was reported for the fungal stains. The provider reported the Gram stain HCPCS code of 87205 for these same three specimens since they also performed Gram stains for bacteria. No additional codes for the fungal stains should have been billed since they were done by the same Gram stain methodology as the bacterial stains. |
| Hospital Outpatient | 13X | Submitted documentation and MD order for CBC w/diff supports code change from HCPCS 85004 (CBC, auto diff WBC count) to HCPCS 85025 (CBC, automated Hgb, Hct, RBC, WBC and platelet count and automated diff WBC count). |
| Hospital Outpatient | 13X | Units are incorrectly coded. Provider billed HCPCS J1756 - injection, Venofer per 1mg, 254 units. Documentation supports Venofer 50mg injection was ordered and given. 250 mg (units). Change units from 254 to 250. |
| Hospital Outpatient | 13X | Code change from 84155 to 84156. Billed code 84155 (Protein, total, except by refractometry; serum), but 84156 (Protein, total, except by refractometry; urine) was ordered and performed. |
| Hospital Outpatient | 13X | Need copy of the automated differential WBC count for billed date of service. Previously submitted documentation did not include the differential. Disagree per SSA 1862(a)(1)(A) and IOM PUB 100-3 Chapter 1 §190.15. Documentation supports only a CBC ordered. No WBC differential report noted with laboratory results. No further new documentation has been received after tech Stop. |
| Hospital Outpatient | 13X | HCPCS Code 93510 is for the billing of left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous. Only 1 unit of HCPCS code 93510 should be billed per date of service. The provider should have billed for 1 unit of this service rather than the 2 units as originally billed. |
| Hospital Outpatient | 13X | HCPCS Code 93005 is for the billing of electrocardiogram, tracing only without interpretation and report. The provider should have billed for 1 unit of this service rather than the 2 units as originally billed. |
| Hospital Outpatient | 13X | HCPCS Code 83519 vs. HCPCS Code 83880- HCPCS code 83519 is for the billing of Immunoassay, analyte, quantitative; by radiopharmaceutical technique. According to the documentation, the provider should have billed HCPCS code 83880, which is for the billing of Natriuretic peptide. |
| Hospital Outpatient | 13X | HCPCS Code 62263 vs. HCPCS Code 62264- HCPCS code 62263 is for the billing of Percutaneous lysis of epidural adhesions using solution injection or mechanical means, including radiological localization, multiple adhesiolysis sessions, 2 or more days. According to the documentation, the provider should have billed HCPCS code 62264, which is for the billing of Percutaneous lysis of epidural adhesions using solution injection or mechanical means, including radiological localization, multiple adhesiolysis sessions, 1 day. |
| Hospital Outpatient | 13X | HCPCS Code 76005 vs. HCPCS Code 76000- A provider submitted a claim for HCPCS code 62311 (epidural steroid injection). This claim also included HCPCS code 76000, Fluoroscopy, billed with modifier 59 to indicate a distinct procedural service for the same DOS. The submitted operative note for the billed date of service did support that fluoroscopy was utilized to locate the L4 – L5 interspace in order to administer an epidural steroid injection. The correct code that should have been submitted was HCPCS code 76005, Fluoroscopic Guidance And Localization Of Needle Or Catheter Tip For Spine Or Paraspinous Diagnostic Or Therapeutic Injection Procedures (Epidural, Transforaminal Epidural, Subarachnoid, Paravertebral Facet Joint, Paravertebral Facet Joint Nerve Or Sacroiliac Joint), Including Neurolytic Agent Destruction. HCPCS code 76005 is a code that is packaged under OPPS with payment included with the APC for 62311. |
| Hospital Outpatient | 13X | HCPCS Code J1245 is for the billing of injection, Dipyridamole, per 10mg, Persantine. Providers are billing units of service equal to the actual milligrams furnished instead of using the definition of a unit inherent in the HCPCS code description. The provider should have billed for 5 units of this drug rather than the 25 units as originally billed. |
| Hospital Outpatient | 13X | HCPCS Code J0256 is for the billing of injection, Alpha 1 – Proteinase Inhibitor-Human, 10 mg., Prolastin. Per the HCPCS Level II 2005 Expert, one revenue unit is equivalent to 10mg. The recommended dosage of Prolastin is 60mg./kg. body weight administered IV over 30 minutes once weekly. Providers have been identified for billing revenue units in excess of the recommended dosage. |
| Hospital Outpatient | 13X | HCPCS Code J9265 is for the billing of Paclitaxel, 30 mg. (Taxol). This drug is administered via IV with doses ranging between 135-200 mg./m2 (body surface area), ranging from weekly to once every three weeks. Providers have been identified for exceeding the norm in revenue units billed for this HCPCS code based upon USPDI recommendations. |
| Hospital Outpatient | 13X | HCPCS Code 45380 is for the billing of colonoscopy with biopsy, single or multiple. The provider billed this HCPCS code twice for the same date of service. Upon review of the CPT Assistant, it appears the provider either billed the code twice for a second biopsy or perhaps the provider intended to bill for the removal of a specimen. This service was not supported by the documentation submitted. |
| Hospital Outpatient | 13X | Documentation submitted did not include physician orders for 82553 – Creatine Kinase; MB Fraction only. Service determined to not be medically necessary. |
| Hospital Outpatient / CAH | 13X and 85X | Missing urinalysis results for DOS billed. This was not included with the order and other lab result sent. |
| Hospital Outpatient / CAH | 13X and 85X | Received per tech stop request copies of the cardiac rehab session reports. Did not receive a copy of the requested lab report for a Prothrombin Time. Received a copy of the cardiac rehab session report but there were no protime results documented on that report. Disagree per SSA 1862[a][1][A]. There is insufficient documentation to support the billed Prothrombin Time for DOS. |
| Hospital Outpatient / CAH | 13X and 85X | Need Outpatient Clinic visit notes for billed DOS. These were not included with the other visit notes sent. Disagree per SSA 1862(a)(1)(A). Missing documentation of clinic visit for billed DOS to support billed service being done. This was not included with the other clinic visit notes submitted. |
| Hospital Outpatient / CAH | 13X and 85X | No response after tech stop request for a copy of the emergency room progress notes to validate general ER charges for billed date of service. Initially received documentation of a copy of the lab and x-ray results for that DOS. Disagree per SSA 1862[a][1][A]. There is insufficient documentation to support the billed ED charges for DOS. Did not receive a copy of the clinical progress notes. |
| Hospital Outpatient / CAH | 13X and 85X | Duplicate billing. Documentation submitted supports both nares were treated for a nose bleed, which was paid on line 3 with a modifier of 50(bilateral). |
| Hospital Outpatient/ CAH | 13 X and 85X | HCPCS J0885 is for Epoetin Alfa injection (non-ESRD use) 1000 units. Documentation did not support the correct amount of units billed. Two units were denied for incorrect coding. |
| Hospital Outpatient/CAH | 13X and 85 X | HCPCS 88305 is for Level IV – Surgical pathology, gross and microscopic exam. No laboratory report for surgical pathology report billed. Unable to determine if service was rendered. Units for this code were denied due to insufficient documentation. |
| Hospital Outpatient/CAH | 13X and 85X | HCPCS 97110 (therapeutic procedure, one or more areas, each 15 minutes) and 97535 (self-care management training). Response to Tech Stop did not include requested documentation. No documentation of total treatment time to support all therapy units billed. Reduced from 4 units to 1 unit for each HCPCS for incorrect coding. |
| CAH | 11X | Revenue code 250: General Pharmacy. Response to Tech Stop with requested itemized billing. Claim billed with 42 units. Documentation shows 32 units were for self-administered drugs. Reduced to 10 units due to non-covered self-administered drugs. |
| Hospital Outpatient/CAH | 13X and 85X | HCPCS 84155 (total protein except be refractory; serum) billed. Documentation submitted supported HCPCS 84156, physician orders and lab results for a total protein except by refractory; urine. Claim was adjusted. |
Skilled Nursing Facility / Swing Bed Identified Errors
| Provider Type | TOB | Error Identified by CERT |
|---|---|---|
| SNF/ Swing Bed | 18X and 21X | The billed RUG-III code requires a minimum of 325 minutes of therapy per week with one therapy at least 5 days. The initial documentation did not include the therapy treatment records for the look-back period. It did include the PT and OT evaluations/plans of care and orders. Tech stop documentation received also did not include the required treatment records which indicated the duration of therapy. A request for the treatment records resulted in only PT treatment documentation copies which do not indicate the duration of therapy and no OT treatment records. It is noted that the therapy was reasonable and necessary, and that the treatment notes and record support participation in therapy on the look-back days. Based on Matrix A, re-RUG from RHC to RMC. |
| SNF | 22X and 23X | HCPCS Code 82962 is for the billing of blood glucose monitoring. Reviews have indicated inappropriate payment of this service. The review decisions were based on the Centers for Medicare and Medicaid Services (CMS) criteria for laboratory services set forth in part in Section 1862(a)(1)(A) of the Social Security Act which requires services to be reasonable and necessary for diagnosis and treatment in order to be covered by Medicare. 42 CFR §410.32 further specifies that for a laboratory service to be reasonable and necessary, it must not only be ordered by the physician but the ordering physician must also use the result in the management of the beneficiary's specific medical problem. Implicitly, the laboratory result must be reported to the physician promptly in order for the physician to use the result and instruct continuation or modification of patient care; this includes the physician's order for another laboratory test. CERT informed that this contractor issued an incorrect payment for services that were medically unnecessary. Targeted reviews for TOBs 22X and 23X billing HCPCS Code 82962 resulted in no claims being submitted. Continue to monitor this billing. |
| SNF | 22X and 23X | HCPCS Code 82948 is for the billing of blood, reagent strip. Fingerstick glucose cannot be billed under a SNF bill type as routine monitoring. A targeted review for TOBs 22X and 23X billing HCPCS Code 82948 resulted in no claims being submitted. Continue to monitor this billing. |
| SNF | 22X and 23X | Service incorrectly coded. Documentation supports code change from CPT 97116-gait training to CPT 97535-self care/home management. Disagree per SSA 1862(a)(1)(A) and IOM PUB 100-04, Chapter 7 Section 40 for Part B Services in a SNF & IOM Medicare PUB 100-02, Chapter 15 Section 220, Coverage of Outpatient Physical Therapy, Occupational Therapy and Speech Pathology Services under Medicare Insurance and IOM PUB 100-04 Chapter 5, sections 10 and 20. |
| SNF | 22X and 23X | Continuous glucose monitoring in the SNF. These tests are not separately payable, and are considered part of the routine care. They are not considered medically necessary. Glucose monitoring may only be covered when it meets all the conditions of a covered laboratory service, including use by the physician in modifying the patient's treatment. "for a laboratory service to be reasonable and necessary, it must not only be ordered by the physician but the ordering physician must also use the result in the management of the beneficiary's specific medical problem. Implicitly, the laboratory result must be reported to the physician promptly in order for the physician to use the result and instruct continuation or modification of patient care; this includes the physician's order for another laboratory service . . . .A standing order is not usually acceptable documentation for a covered laboratory service." The documentation submitted does not support that the physician was notified of the results of the testing. Documentation submitted by the provider included an order from the physician for accu check qid x 7 days. Provider submitted a nursing flow sheet with accu checks recorded qid for thirty-one days. For DOS billed, there is no indication that the physician was notified of the results of the accu checks and no treatment is recorded. Documentation submitted includes the patient's location recorded as being in the LTC facility. |
| SNF | 22X and 23X | Need documentation of initial evaluation / recommendations for pulmonary rehab and documentation of physician referral for the program. Daily treatment notes have been previously received. Tech stop with no additional documentation. Disagree per SSA 1862(a)(1)(A) and LCD (LMRP) - FI - Cahaba Government Benefits Admin [00011] - IA, SD - Pulmonary Rehabilitation - Outpatient #OA02-001 (Rev. Eff. 08/17/2004). Missing MD order for pulmonary rehab as well as physician evaluation to support that the service is reasonable and necessary for this beneficiary. Only the treatment notes are submitted. Documentation does not support the medical necessity of the services billed. |
Page last updated: May 7, 2008
