Medicare Part B Payments for End-Stage Renal Disease Dialysis Services and Comprehensive Error Rate Testing (CERT)


Medicare Part B covers outpatient dialysis services for beneficiaries diagnosed with end-stage renal disease (ESRD). Previously, the Office of the Inspector General (OIG) identified inappropriate Medicare payments for ESRD services. Specifically, OIG identified unallowable Medicare payments for treatments not furnished or documented, services for which there was insufficient documentation to support medical necessity, and services that were not ordered by a physician or ordered by a physician that was not treating the patient. (Social Security Act §§ 1862(a)(l)(A) and 1833(e), 42 CFR §§ 410.32(a) and (d), 42 CFR §§ 410.12(a)(3), 424.5(a)(6), and 424.10).

For Jurisdiction M, CERT errors were related to CPT code 90960, ESRD-related services monthly for patients 20 years of age and older, with 4 or more face-to-face visits by a physician or other qualified health care professional per month. Also noted was CPT code 90961, ESRD-related services monthly for patients 20 years of age and older, with 2–3 face-to-face visits by a physician or other qualified health care professional per month.

CERT Error code 31 — Incorrect Coding — Example
Incorrectly coded and changed from CPT code 90961 to 90962. Documentation submitted supports a CPT code change from 90961 — dialysis visits 2–3 with physician monthly — to 90962, ESRD-related services monthly for patients 20 years of age and older with one face to face visit per month supporting only one visit during dialysis for services billed on 0X/0X/20XX.

The 31 error code means the documentation submitted for review by the provider does not match the codes billed for the claim. To prevent this error, make sure this documentation is submitted in the record for review.

  • Make sure the date(s) of service are documented
  • Ensure the proper principle diagnosis and principle procedure is coded correctly
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all of the essential pieces are included in the record
  • Make sure that both sides of double-sided documents are submitted
  • Remember it is the billing provider’s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation

CERT Error code 16 — No Documentation — Example
Provider indicates that a record could not be found for the specified date of service. Documentation to support billed ESRD monthly related services of 2–3 face-to-face encounters for billed date 8/1/XX. Received note that states "Unable to locate physician documentation to support the service, billing error. Please initiate overpayment recoupment."

When a provider receives a Comprehensive Error Rate Testing (CERT) error for no documentation or insufficient documentation, it means that elements of the medical record that are imperative for Medicare payment were not sent in to the CERT contractor for review. Here are some tips to prevent this error:

  • Submit signed (with credentials) and dated orders to cover dates of service billed
    • If the signed and dated orders are illegible, obtain a signature log
    • If using standing orders, make sure they are up-to-date
    • If electronic orders, include policy and procedure related to using electronic signatures
  • Submit signed (with credentials) and dated progress or treatment notes that show the medical necessity for ESRD to cover the dates of service billed
    • If progress/treatments notes are not signed, obtain an attestation from the physician
    • Include progress/treatment notes on and prior to the date of service to ensure documentation reflects medical necessity for ESRD treatment
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all of the essential pieces are included in the record
  • Make sure that both sides of double-sided documents are submitted
  • Review ESRD Billing and ESRD Payment for more information
  • It is the billing provider’s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation

Dialysis services, such as CPT codes 90935 and 90960–90963 (clinic ESRD) ESRD Monthly Capitation Payment (MCP) Coding and Frequency Limitations were listed on the Top 20 Types of Services with Insufficient Documentation Errors on the Comprehensive Error Rate Testing (CERT) report for 2020.

Missing supportive documentation may include daily treatment records, progress notes, etc. Documentation submitted supports CPT/HCPCS code change.

Prior OIG reviews identified claims that did not comply with Medicare consolidated billing requirements (the Act § 1881(b)(14), Medicare Claims Processing Manual, Pub. No. 100-04, Ch. 8 and Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 11) for Medicare Part B dialysis services provided to beneficiaries with ESRD.

Information concerning ESRD Monthly Capitation Payment (MCP) Coding and Frequency Limitations may be located on the Jurisdiction J Part B and Jurisdiction M Part B websites.

The ESRD PPS includes consolidated billing requirements for limited Part B services included in the ESRD facility’s bundled payment. CMS periodically updates the lists of items and services that are subject to Part B consolidated billing and are therefore no longer separately payable when provided to ESRD beneficiaries by providers other than ESRD facilities.

Providers have 120 days to appeal from date of demand letter and also have the option to submit the missing documentation to CERT with the barcoded coversheet request .Please keep in mind that the appeals time line is ongoing regardless of sending in the documentation to CERT for re-review. The benefit to submitting the documentation directly to CERT has the potential to have the error removed entirely.

Appeals must be requested within 120 days of request for funds regardless if the documentation was sent to CERT or not. 

Resources

 IOM References include:

  • PUB 100-02 Ch. 11 (ESRD) §50.A (ESRD PPS Base Rate; Per Treatment Unit of Payment)
  • PUB 100-02, Chapter 6 § 20.5.2 (Coverage of Outpatient Therapeutic Services Incident to a Physician's Service)
  • PUB 100-04 Ch. 8 (Outpatient ESRD), §10 (General Description of ESRD Payment and Consolidated Billing Requirements) and §50.6.2 (Payment for Hemodialysis Sessions)
  • PUB 100-08 Ch. 3 §3.3.2.4 (Signature Requirements- Orders)
  • PUB 100-08, Chapter 3, Section 3.3.2.4.C (Signature Attestation Statement)




Last Updated: 12/11/2020