CERT Spotlight: Nursing Home Visits
On the November 2005 Comprehensive Error Rate Testing (CERT) report the CERT contractor, AdvanceMed, reported a 19.3% paid claims error for nursing home visits billed by physicians in South Carolina. There were 46 claims in the sample totaling a paid amount of $1,782.00. Of the claims sampled the dollars paid incorrectly totaled $343.00. Using the error rate of 19.3%, AdvanceMed projected a total dollars paid incorrectly for South Carolina nursing home visits to be $1,651,991.00.
For all carriers in the nation, procedure code 99312 ' nursing facility subsequent - had a 2.8% error rate due to 'no documentation' resulting in a projected improper payment of $11,899,626.00 for the November 2005 reporting period. No documentation means the provider did not submit any documentation to support the services provided. Subsequent nursing facility care codes 99311 ' 99313 have been deleted for calendar year 2006 and replaced with 99307 ' 99310 effective January 1, 2006. For the nation, errors for no documentation accounted for 0.7% of the total dollars all Medicare fee for service contractors allowed during the November 2005 reporting period.
The majority of errors for nursing home visit services from South Carolina physicians resulted from 'no documentation errors.' One physician sent a note to AdvanceMed that stated 'We do not have any records for this date of service. Please contact nursing home for this.' AdvanceMed has no way of knowing which nursing home the patient was in at the time of the visit and are not responsible for trying to determine where to send the record request. To satisfy the request for records, the billing provider must submit information. The billing provider should contact the facility for the appropriate records and forward those to the CERT documentation contractor.
All errors found by the CERT contractor result in overpayments by Palmetto GBA to recoup funds paid to the provider in error. All documentation to support services billed should be sent to AdvanceMed or the CERT documentation contractor immediately upon request to avoid an overpayment.
Information on correctly coding evaluation and management services can found on our Web site at www.PalmettoGBA.com. Select Part B Carrier from the drop down box on the right hand side. Next, select Learning and Education from the drop down box. Then, choose workshop handouts on the left hand side of the page. And finally, choose 2005 Medicare Part B Evaluation and Management Workshop Handout.
Additional information about the CERT program can be found at http://www.cms.gov/cert.