Cahaba has noted recent errors related to genetic testing codes for CERT reviewed claims (cpt codes: 81225, 81226, 81240, 81241, 81291, 81350, 81400, 81401, 81402, 81403). Insufficient documentation to support medical necessity of the service accounted for the vast majority of the errors at 77%. Eleven percent of the errors were due to a missing valid physician order. The final two error categories were: service was not medically necessary (7%) and missing laboratory results (5%). When claims are reviewed, all Medicare coverage, payment and billing rules and regulations are used to determine whether the claim is payable or was paid correctly. This includes following all related Local Coverage Determinations (LCDs) that apply. You can locate Cahaba’s LCDs on the Cahaba website at https://www.cahabagba.com/.
Three of the four error categories identified by CERT involve missing and insufficient documentation, making this the biggest driver of genetic testing errors. Providers should carefully review the detailed list of requested documentation when a claim is selected for review and completely comply by submitting all documentation components noted in the request. When claims are reviewed, clinical documentation is required to support the medical necessity of the laboratory service. All providers, including laboratories, are responsible for obtaining documentation housed by third parties to support the claim as billed. For laboratory providers, this often means documentation must be obtained from physician offices. Physician offices are responsible for providing laboratories with documentation, when requested, to support services ordered by the physician and provided by the laboratory. Missing laboratory test results were also identified as a problem. Results of the tests performed are a required piece of documentation in the review process and must be provided to support the billed service.
Seven percent of the errors were due to a lack of medical necessity for the service. The Social Security Act stipulates that Medicare may only pay for services that are reasonable and necessary, and specifies the requirement for documentation of services in order to help establish the medical necessity of services rendered. Medical necessity is defined as: health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Many of the errors identified on review of the genetic testing codes might possibly be avoided by adhering to the CERT process. Once claims are selected for CERT review, Additional Documentation Request (ADR) letters are generated for each claim to be reviewed. The CERT request includes detailed information and directions you will need to follow in order to be compliant with the request. In order for your claim to be properly reviewed, you must submit the documentation that supports the Medicare claim. Providers have 45 days, from the date of the initial ADR letter, to return requested documentation. The CERT contractor makes an extensive effort to obtain documentation from providers. However, if the requested documentation is not received, the claim is counted as an error on day 76 and is subject to overpayment recovery. This means if a provider does not return the requested documentation, the claim will be denied 76 days after the date on the ADR letter.
To avoid errors, providers must:
- Review the requested documentation in the ADR letter
- Submit all requested documentation components
- Adhere to the established CERT timelines
Encourage your office to get educated today and stay up-to-date on CERT processes/issues by visiting the CERT Review Contractor website at: https://certprovider.admedcorp.com/.