The National Government Services (NGS), the Medicare Administrative Contractor (MAC) for Jurisdiction K (Massachusetts) and Jurisdiction J (parts of New York), published their findings of a review of arterial and venous ultrasound claims that were performed on the same day in July, August and September of 2014. The findings include a breakdown of the number of claims that were denied or reduced, as well as a list of reasons for the denials/reductions.

Before we get to the reasons for reduction or denial, let’s look at the reported data from those months:

  • June – 952 services billed; 665 (60.3%) were reduced or denied
  • August – 1,894 services billed; 1,169 (56.8%) were reduced or denied
  • September – 1,952 services billed; 1,330 (57.9%) were reduced or denied

It seems to me like a lot of claims – well over half – are not paid or paid less than the service provided. But this isn’t really that bad when you look at the pre-payment audit results for Rhythm ECG (93042), which for the same time period, had a reduction/denial rate of nearly 99%. You read that correctly – 99%. Many of the same reasons for reduction or denial are listed.

The MAC, which is also affected by the budget crunch, doesn’t want to pay for services if they don’t have to. This pre-payment audit is looking for providers who don’t follow the rules for reimbursement, but the MAC was kind enough to list the most common reasons for these denials and reductions. Let’s take a look at these reasons:

  • “Documentation did not meet the noted LCD requirements” – the LCD (Local Coverage Determinations) detail the coverage limitations, including equipment, indications, other tests, etc., that will determine whether or not a service is covered. If the provider (the physician or facility billing the study) submits a claim that doesn’t align with the LCD, it will be reduced or denied.
  • “The documentation lacked clinical indications to support the medical necessity of the study” – this pertains to the patient’s medical record. When the MAC asks for documentation to support medical necessity, they are asking for the patient’s medical record. The medical record should state the reason for the exam that was billed. For instance, if an order for a carotid duplex exam states that the patient presented with a transient ischemic attack (TIA), the medical record should state the onset, frequency, duration, and location of the patient’s symptoms of a TIA; essentially supporting the medical necessity for the carotid study. It is not appropriate to order a study for an indication that will be reimbursed just because you want the study performed. An important thing to remember is that the patient’s chart notes also need to state how the performance of the study will affect the treatment plan for the patient. If the study is going to have no effect on how the course of treatment will go for the patient, then the study is not medically necessary. Duh.
  • “A bilateral study was billed but the documentation supported for a (sic) unilateral study” – sometimes the physician will order a bilateral study, but the medical necessity was not established for both sides. For instance, an order for a venous study might be ordered bilaterally, but the order says “right lower extremity edema”. The patient might have a condition that puts him or her at risk for bilateral deep venous thrombosis (DVT), like cancer or trauma, and the physician might feel that the bilateral exam is medically necessary, but the medical record doesn’t clearly reflect this. Also, some vascular labs might have a testing “algorithm” that says to do both legs, but if it’s not ordered, you can’t bill for it.
  • “Nonresponse to development requests” – Really? The MAC asked for more information and the provider didn’t respond? I know, this might be an oversight on the provider’s part, or a provider that is outside of the practice, like an outpatient facility, might not have ready access to the patient medical record, but jeez, you should respond shouldn’t you?
  • “No documentation was submitted for the billed CPT code(s)” – Well, this could be the order, the final report, or the proper paperwork, so it might just be an oversight on your part as the provider. But this happened enough times that it made their list of reasons for reduction/denial, so it must be pretty prevalent. This seems a little disorganized to me.
  • “Duplicate services were billed” – this could be that someone else from another facility may have billed the provider for the same service. Or it could be that the provider billed the same code twice, like billing 93971 twice because the study was bilateral. The first explanation may be beyond the control of the provider. It’s hard to know if another physician ordered a study at another facility. But the second explanation is harder to dismiss. The provider has to know that this is not acceptable. It could be construed as an attempt to get more out of the system than one is owed. Just saying.
  • “The documentation was incomplete or missing information in regards to the beneficiary who was being treated” – This definitely seems like an oversight or a poor system for submitting billing.
  • “The rendering physician submitted on the claim form was not the physician who performed the service(s) per the submitted documentation” – This could happen in a multi-physician practice or a hospital, or anywhere billing is done for more than one physician. It may be difficult to put systems in place to catch this, but human error does occur. Training your staff on the importance of correct billing and coding procedures might go a long way to avoiding this one.
  • “Missing or illegible provider signature” – with regard to this reason, the NGS report, as well as the LCD, states, “Documentation must be legible and include a provider’s signature. The method can either be electronic or handwritten. Stamped signatures are not acceptable.” This seems like a no-brainer but it still happens. This rule has been around for many years and providers still have difficulty with this one.

These seem like perfectly avoidable reasons for reduction or denial of payments, don’t they? But many times the provider of the service, whether it is the technical or professional component of the service, is not the physician ordering the study. A hospital or another practice does not always have access to the patient medical record to submit proper documentation, or the provider may request an order with a proper indication and a valid signature, but the referring physician’s office doesn’t provide the required information. What could start happening, in these times of economic difficulties, is that certain providers will stop accepting patients from referring physicians who do not order appropriate studies, or don’t provide proper documentation, or who don’t work the provider to assure that the provider is able to keep providing appropriate care by getting paid for the work that they do. What are the referring physicians going to do? Send the patient somewhere else? The other providers have follow the same exact rules so eventually they’re going to have to comply, right?

So here are some lessons that I learned from this report, if I was the provider of a service:

  1. Follow the rules outlined in the LCD
  2. Provide details in the patient’s chart about the medical necessity of the study ordered
  3. To assure medical necessity, the test must affect the decision making process in the patient’s treatment
  4. Order unilateral when indicated, bill for unilateral when ordered, and get a new order if more is necessary
  5. Respond to requests for more information
  6. Get organized and submit your documentation
  7. Try not to bill for a study that someone else did, and don’t try to get more than you’re owed
  8. Pay attention to details on your claims
  9. Avoid errors by training the staff to lessen the errors
  10. The referring physician and the provider need to work together so that the patient receives appropriate care in a timely and cost effective manner

Whew, that was a long one. But if you’re going to provide quality patient care, you should get paid for it. If you’re trying to get around the rules, you shouldn’t get paid. If a rule seems dumb, try to change it, but keep following the rules until they’re changed or you’ll get in trouble. Duh.