March 2012 CERT Errors
In an effort to help reduce the CERT Error Rate, NHIC, Corp. DME MAC A is providing monthly claim examples reviewed by the CERT contractor, resulting in the top CERT Errors. As you review this information, consider the missing documentation that caused the error.
NHIC, Corp. DME MAC A expects these examples will assist suppliers in understanding the CERT review process, and to become familiar with the type of medical records requested.
For information on coverage and documentation requirements, you may access the applicable Local Coverage Determinations (LCDs) at the following web site: http://www.medicarenhic.com/dme/medical_review/mr_lcd_current.shtml
The following examples are errors cited during the CERT review for March 2012:
1. Lower Limb Prostheses – LCD L11464
L5700-RT – Replacement, socket, below knee, molded to patient model
L5637-RT – Addition to lower extremity, below knee, total contact
L5629-RT – Addition to lower extremity, below knee, acrylic socket
L5620-RT – Addition to lower extremity, test socket, below knee
L5685-RT – Addition to lower extremity prosthesis, below knee, suspension/seating sleeve, w/ or w/o valve
L5668-RT – Addition to lower extremity, below knee, molded distal cushion
L5647-RT – Addition to lower extremity, below knee suction socket
L5940-RT – Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)
L5679-RT – Addition to lower extremity, below knee/ above knee custom fabricated from existing mold or prefabricated
L5645-RT – Addition to lower extremity, below knee, flexible inner socket, external frame
L5972-RT-K2 – All lower extremity prostheses, flexible keel foot
L5986-RT-K2 – All lower extremity prostheses, multi-axial rotation unit
Date of Service: 11/15/11
o Received – Multiple CPO notes; orders; office visit notes dated 12/08/11 documents normal gait and assessment of muscle strength and tone; unsigned PT initial evaluation; unsigned image report; a letter dated 02/15/12 from ordering physician that documents “She cannot walk and is wheelchair dependent”; Doppler report dated 04/14/11; x-ray report dated 07/29/10. duplicate visit note dated 12/08/2011.
o Missing – Treating physician’s clinical documentation that supports the beneficiary will reach or maintain a defined functional state within a reasonable period of time with use of prostheses; documentation that supports the beneficiary is motivated to ambulate; documentation that supports the beneficiary’s potential functional abilities, past history (including prior prosthetic use if applicable), current condition including the status of the residual limb, and the nature of other medical problems; clinical documentation supporting medical management and continued use of prostheses, including reasons for replacement items (a change in the physiological condition of the patient; or irreparable wear of the device or a part of the device; or the condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or of the part being replaced).
L5980-K3-RT – All lower extremity prostheses, flex foot system
L5986-K3-RT – All lower extremity prostheses, multi-axial rotation unit
Date of Service: 10/27/11
o Received – MD order; supplier forms; prosthetist’s form dated 12/02/11 that provides the beneficiary’s history but does not include information regarding the replaced prosthetic; progress note dated 10/20/11 that is illegible; an additional office visit note dated 10/20/11 that does not address prosthesis and residual limb; office visit note dated 10/27/11 that does not have a legible identifier and does not address the prosthesis and residual limb; an order for the prosthesis that notes ‘uses prosthesis’; prosthetist’s notes dated 10/10/11 through 10/27/11; signed and dated order for the prosthetic component parts, including flex foot and multi-axial rotation unit; an attestation from the prosthetist that does not include dates the author is attesting to; prosthetist’s clinical assessment dated 10/27/11; duplicate documentation.
o Missing – Treating physician’s clinical documentation supporting that the beneficiary will reach or maintain a defined functional state within a reasonable time frame; clinical documentation from the treating physician that includes the beneficiary’s past medical history, including prior prosthetic use, current condition, including the status of the residual limb, and assessment of beneficiary’s rehabilitation potential based on classification levels 0-4, current functional capabilities, and expected functional potential with explanation for the difference.
2. Oxygen and Oxygen Equipment – LCD L11468
K0738-RR – Portable gaseous oxygen system; home compressor
Date of Service: 09/22/11
o Received – Initial CMN dated 01/20/09; Recertification CMN dated 01/22/10; prescription dated 01/22/09 for home oxygen; Office visit notes from treating physician; delivery tickets from supplier dated 01/20/09 and 03/24/09; physician’s order sheet dated 01/20/09 to “check ABG on room air” and “SW for home O2 2l NC 24 hours/day” with an illegible signature; hospital orders dated 01/19/09 for ambulating pulse ox on RA with attached note, “unable to do, pt sats 86% at rest dated 01/20/09.” Note: Submitted treating physician office visit notes support that the beneficiary has emphysema that is expected to improve with oxygen therapy and continued use of oxygen and that beneficiary requires oxygen with ambulation which supports mobility requirements.
o Missing – Signed copy of the qualifying oxygen study (reported on the recertification CMN as performed on 01/20/09 as 86%) with the beneficiary in a chronic stable state as an outpatient.
E0439-RR – Stationary liquid oxygen system
E0434-RR – Portable liquid oxygen system
Date of Service: 09/01/11
o Received – Initial and recertification CMN portable equipment; Initial CMN for liquid equipment dated 12/01/09; recertification CMN dated 12/01/10 for oxygen at 2 liters; order dated 03/07/11 with higher flow rates for oxygen “6 liters with exertion and 5 liters at rest and bedtime”; delivery ticket; order dated 01/10/07 to switch to liquid; pulse ox study dated 06/16/04; office visit notes dated 06/03/11; admission note dated 04/26/11; discharge note dated 05/08/11; sleep study dated 06/15/11; office visit note from the billing provider dated 10/18/10 and 02/20/12 that supports medical management and continued need and use (these 2 notes also support the beneficiary is using 4 liters at day and night and 6 liters with activity).
o Missing – Signed and dated copy of qualifying oxygen saturation study, obtained during rest on 12/01/10; Revised CMN to reflect the new order for the change in flow rate.
3. Glucose Monitors and Supplies – LCD L11530
A4253-NU-KS – Blood Glucose test or reagent strips for Home Blood Glucose Monitor, per 50 strips
# of units billed = 2
Date of Service: 06/01/10 to 06/25/10
o Received – Pharmacy summary; Physician’s Order for Glucose strips and lancets to test qid; Ha1c level of 6.9% and Glucose 164mg/dl dated 07/13/10; several progress notes supporting physician oversight of a non insulin dependent diabetic (each note indicating the beneficiary performs home glucose testing and indicating a range, however there is no documentation that adequately reflects the medical necessity and compliance of home glucose testing as the physician ordered and the specific reason for exceeding utilization guidelines).
o Missing – Documentation that adequately reflects the medical necessity and compliance of home glucose testing qid as the physician ordered and the specific reason for exceeding utilization guidelines which includes the legible identification of the person performing and documenting the service.
A4258-KL-KS – Spring-powered device for lancet, each
# of units billed = 1
A4259-KL-KS – Lancets, per box of 100
# of units billed = 2
A4256-KL-KS – Normal low and high calibrator solution/chips
# of units billed = 1
A4253-KL-NU – Blood Glucose test or reagent strips for Home Blood Glucose Monitor, per 50 strips
# of units billed = 4
Date of Service: 10/21/11 to 01/20/12
o Received – Order for home glucose testing supplies; a delivery ticket.
o Missing – Treating physician’s clinical records that document the specific reason(s) for an ordered testing frequency of twice daily, which is in excess of utilization guidelines for a non-insulin dependent diabetic (as indicated by the use of the KS modifier on the claim); clinical records that include an evaluation of the beneficiary’s diabetic control within six months prior to the order date which exceeds utilization guidelines; clinical records that support medical management of the beneficiary’s diabetes, and document the actual frequency at which the beneficiary is testing.
4. Power Mobility Devices – LCD L21271
K0800-NU-KX – Power Operated Vehicle, group 1 standard, patient weight capacity up to and including 300 lbs
Date of Service: 09/19/11
o Received – Physician office visit notes 07/12/2011 and 07/20/2011; delivery ticket, ABN and home evaluation dated 09/19/2011; ABN dated 09/19/2011; and detailed product description dated 07/27/2011.
o Missing – Face-to-face evaluation elements to support a sufficiently detailed evaluation of the beneficiary, including mobility limitations that affect participation in mobility-related activities of daily living (MRADLs) in objective language regarding strength, balance, endurance and gait; documentation of why the beneficiary’s mobility limitations are not able to be resolved by use of an appropriately fitted cane, walker, or manual wheelchair.
K0821-RR-KI – Power wheelchair, group 2 standard portable, captain’s chair
Date of Service: 12/02/11
o Received – ABN; 7-Element Order dated 06/17/11; Detailed Product Description dated 06/17/11; Weekly occupational therapy weekly notes; illegible signed and dated progress note/face to face exam dated 06/17/11; delivery ticket; Home evaluation; ultrasound report dated 02/03/12; a note from the ordering physician stating, “No documentation at office. Pt is not seen here. You must contact assisted living where they are seen for documentation.”
o Missing – Face-to-face mobility evaluation elements to support that the beneficiary has a mobility limitation that significantly impairs the ability to participate in MRADL’s that cannot be sufficiently resolved by use of a cane, walker, and manual wheelchair; supporting documentation that the beneficiary continues to need and use power wheelchair.
5. Ankle-Foot/Knee-Ankle-Foot Orthosis – LCD L11527
L4360-RT-KX – Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, pre-fabricated, includes fitting and adjustment
Date of Service: 11/15/11
o Received – An authenticated orthopedic surgeon note dated 09/23/11 that supports the beneficiary being status post ORIF of a trimalleolar right ankle fracture and is non-weight bearing; unauthenticated notes dated 09/20/11 and 09/26/11-12/14/11.
o Missing – A valid signed and dated order for a walking boot; authenticated documentation that supports the beneficiary is ambulatory with weakness or deformity of the foot and ankle requiring stabilization.
L1960-LT-KX – Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
L1960-RT-KX – Ankle foot orthosis, posterior solid ankle, plastic, custom-fabricated
L2275-LT-KX – Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
L2275-RT-KX – Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
L2820-LT-KX – Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
L2820-RT-KX – Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
Date of Service: 10/28/11
o Received – Order dated 9/19/11; prosthetist’s documentation (evaluation, measurement, fitting and delivery).
o Missing – Clinical documentation of medical condition requiring custom-fabricated ankle/foot orthosis, reason prefabricated AFO cannot be used, and the ambulatory status; documentation supporting medical oversight.
• Medicare requires that all documentation must be dated, and must be able to authenticate the author with a valid handwritten or electronically signed signature. Please refer to the Supplier Manual for guidance on signature requirements: http://www.medicarenhic.com/dme/suppmandownload.shtml
• Suppliers have appeal rights on claims denied as a result of a CERT audit. A redetermination request may be submitted following the same guidelines as any other redetermination request. However, the supplier must identify the appeal case as a CERT case. If the supplier is using the CMS “Medicare Redetermination Request Form”, be sure to mark:
o “Overpayment Appeal” as “Yes”
o “If yes, who requested overpayment” as “CERT”
o And to also include the CERT CID# in the Reasons/Rationale section.
If the supplier is using their own redetermination request form, please identify the appeal case as a CERT case by including verbiage, such as: “This is a CERT case” and be sure to include the CERT CID#.
• “Dear Physician” letters are available to assist you in identifying pertinent medical records:
• CMS provides a variety of products to assist providers in their efforts to comply With Medicare standards. The Provider Compliance National Educational Products web page includes fact sheets on Oxygen and Equipment, Glucose Monitors and Supplies, and Signature Requirements: http://www.cms.gov/MLNProducts/Downloads/ProvCmpl_Products.pdf
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