On the November 2005 Comprehensive Error Rate Testing (CERT) report, the CERT contractor, AdvanceMed, reported a 20.4 % paid claims error rate for cardiovascular stress tests for physicians in South Carolina. The specialty of cardiology had a 6.7% error rate for all carriers in the nation resulting in a projected improper payment amount of $379,553,992.00 for all services rendered by cardiologists.
The paid claims error rate for South Carolina came from errors found on six claims from the randomly selected claim sample. One claim contained improper documentation, one service was incorrectly coded and four claims contained insufficient documentation to support the service billed.
The claims in the sample are part of the BETOS (Berenson Eggers Type of Service) group Other Tests, Cardiovascular Stress Tests, category T2B, which includes procedure code ranges
93015 ' 93018 (Cardiovascular Stress Test), 93350 (Echocardiography, transthoracic) and 93741 ' 93744 (Electronic Analysis of pacing cardioverter-defibrillator) . Some coding guidelines for the above codes include:
93015 ' 93016: These codes require the physician to be immediately available in the office suite due to the high risk inherent in the procedure. Payment will only be made in cases where the medical record clearly documents there was physician supervision during the exercise stress test. The clinical record should also document the findings supporting the diagnosis and the indication(s) for the test. When pharmacological stress is used, the record must show clinical evidence supporting the reason exercise was not possible. Medicare does not cover screening diagnostic testing.
93350: Echocardiography performed for screening purposes is NOT covered. When a screening test is performed, use an appropriate screening ICD-9 code to indicate the test is being done for screening purposes. When the result of the test is abnormal, subsequent services may be billed with the test-result diagnosis; however, the initial screening test must be documented as a screening, even though the result of the screening test may be a covered condition. Symptoms of an existing condition must be present and documented to meet medical necessity. Diagnostic injections are an integral part of a contrast procedure and are not separately payable.
General guidelines: The patient's medical record must document the medical necessity of the service performed for each date of service submitted on a claim and each page of documentation should include the date and the beneficiary's name. Documentation must be available on request. If the documentation requested by AdvanceMed is not readily available in your facility, it is the billing provider's responsibility to obtain the required records and provide them for review.
Additional information about the CERT program can be found at
http://www.cms.gov/cert.