In the November 2005 Comprehensive Error Rate Testing (CERT) report the CERT contractor, AdvanceMed, reported a 17.2% paid claims error rate for all services in the BETOS (Berenson Eggers Type of Service) category P6B, Minor Procedures ' Musculoskeletal, billed by physicians in South Carolina. This error rate is much higher than the national rate of 1.6% according
to the most recent data available May 2006.
Analysis of the claims paid in error resulted in the following information.
The specialty of orthopedics (20) had the most claims paid in error, followed by physical medicine and rehabilitation (35)and
podiatry (48).
- According to reports from AdvanceMed, the largest percentage of errors was due to lack of sufficient documentation to support the service billed was rendered.
- Any documentation submitted must adequately describe the service as defined by the © CPT code, HCPCS code and/or HCPCS modifier billed.
- Injections must be documented by including the site of the administration, the name of the drug used and the amount given in each site of injection.
An example of insufficient documentation would be: 'We have injected him under sterile conditions with Kenalog and Marcaine.' In this example the provider had billed Medicare for two units of arthrocentesis, aspiration and/or injection of a major joint or bursa (20610) and sixteen units of triamcinolone acetonide, (Kenalog, J3301). Because the documentation submitted did not describe the injection site(s) or the amount of the drug that was injected, an error was called on the claim. In the case above, AdvanceMed instructed Palmetto GBA to recoup all the monies paid to the provider because the documentation did not adequately describe the services billed.
Other helpful CERT tips:- All documentation should contain a legible beneficiary name, first and last, the name should exactly match the beneficiary's Medicare card as that is the name that we have in our claims processing system.
- All documentation should contain a legible provider signature; if the provider signature is not legible the name should be printed below the signature.
- All documentation should contain the date the service was rendered.
- It is the responsibility of the billing provider to obtain documentation from other entities to support the services if the billing provider does not keep the documentation on file.
Additional information about the CERT program can be found at
www.cms.gov/cert.