1. Medicare’s medical review process
May 2013

2. Objectives Understand how Medicare’s Medical Review Program works
Identify the types of services that are currently being reviewed by Medicare
Become familiar with your role in the Medicare review process
Learn more about the common errors from recent Medicare audits
Take advantage of the resources available to you

3. Medicare’s Medical Review Process
Medicare contractors are required to develop processes to help ensure appropriate billing and proper claim payment
MR may request documentation to support billed services
Providers must supply documentation
Documentation must support medical necessity and codes billed
Documentation must be legible and signed
Providers benefit from this program by:
Reducing the overall claims payment error rate
Reduction in filing errors
Increase in timely payments, and
Increased educational opportunities

4. The Provider’s Role
The purpose of the MR process is to make sure claims are paid correctly. You can help meet this goal by:
Reviewing and reading all publications and LCDs so you are aware of coverage requirements
Familiarizing office staff and billing vendors with filing rules
Checking your records against billed claims
Performing self audits

5. Medicare audit contractors
Recovery Audit Contractors (RACs)
Comprehensive Error Rate Testing (CERT)
Zone Program Integrity Contractors (ZPICs)
Medicare Administrative Contractors (MACs)
September 20, 2018
© 2013 Copyright, CGS Administrators, LLC.

6. CGS MR Strategy - 2013 Drugs Hospital Visits – Initial and Subsequent
Ambulance
Nursing Home Visits
Chiropractic Manipulative Treatment
Physical Therapy
Office Visits - Established
Office Visits – New
Emergency Room Visits
Modifiers 24, 25, 57
Lab Tests
New Providers
Surveillance
Medical Review Edits
Currently Reviewing
Drugs-Herceptin, Hospital Visits, Locum Tenens, Modifier 25, Nursing Home Visits, and Office Visits

7. Types of Review
Widespread: When a particular kind of problem is identified (i.e., errors in billing a specific type of service)
Provider-specific (probe): When atypical billing patterns are identified

8. How the MR Process Works: Initiating Documentation Requests
Postpayment Review: Providers receive record request letters directly from the CGS MR Department via standard mail.
Widespread Prepayment Review: Notification of widespread prepayment review initiated by the CGS MR are posted on the CGS Website and ListServ.
Provider Specific Prepayment Review: If the provider is undergoing a prepayment review initiated by CGS MR, the provider will receive a notification letter from the Medical Review Department.

9. Responding to Documentation Requests
Providers have 30 days to respond to requests for medical records.
If documentation is not received within 45 days, the claim will be reviewed based on information at hand.
If medical records are necessary for a determination and not received, the services will be denied.

10. How the MR Process Works: Submitting Documentation
Providers have three options for submitting documentation.
Fax
Mail
Electronic Submission of Medical Documentation (esMD)

11. How the MR Process Works: Faxing Documentation
A cover sheet is provided for all post-payment review record requests; complete the cover sheet provided.
Place the cover sheet and a copy of the record request letter on top of the documentation, ensuring the cover sheet is the first page of your fax.
Fax to
Note: CGS can accept any volume of documents via fax. This mechanism delivers your documentation directly to MR without the need for human intervention or sorting, helping to ensure the timely processing of your claims.

12. How the MR Process Works: Mailing Documentation
A cover sheet is provided for all postpayment review record requests; complete the cover sheet provided.
Place the cover sheet and a copy of the record request letter on top of the documentation. Please ensure the cover sheet is the first page of your mailing.
Mark the mail-piece “Confidential” and send to:
Part B Correspondence
Attention: Part B Medical Review
CGS Administrators, LLC
PO Box 20018
Nashville, TN
Note: In accordance with safety precautions suggested by the United States Postal Service, please remember to include your return address on the mail-piece. We will not open any mail that does not clearly identify the sender.

13. How the MR Process Works: Sending Documentation via esMD
A cover sheet is provided for all postpayment review record requests; complete the cover sheet provided.
Create and complete one copy of the cover sheet per claim.
Identify each claim’s documentation in esMD by entering the Documentation Case ID Number (Doc Case ID Num) found on the Medical Records Request list that accompanies the record request letter.

14. Electronic Submission of Medical Documentation (esMD)
CGS Administrators, LLC.
April 1, 2013
Electronic Submission of Medical Documentation (esMD)
CMS established a new mechanism for submitting medical documentation to Review Contractors
More info:
Background
2013 Copyright, CGS Administrators, LLC.

15. Progressive Corrective Action
During a probe review (20-40 claims/provider) or a widespread review (100 claims/multiple providers), providers are notified that the review is being conducted and asked to provide documentation for the claims in question.
Once the review is completed, providers are notified of their results.
If a review verifies that errors exist, it is classified as minor, moderate, or significant.
Results determine which corrective actions are needed:
Provider education,
Prepayment (review prior to payment) review, or
Postpayment (review after payment) review,
Both pre and post payment review require providers to submit documentation.
Once providers have re-established correct billing, they are removed from review.

16. From recent Medicare audits
Key Findings
From recent Medicare audits

17. Signatures in the Medical Record
Acceptable forms of signatures:
Legible handwritten signatures
Handwritten signatures should be legible and the reviewer must be able to determine whose signature is used
If signature illegible, use the Attestation Statement:
Or, include a signature log with your documentation
Electronic signatures
Should contain date and timestamps and include printed statements, e.g., “electronically signed by,” or “verified by,” followed by the practitioner’s name and preferably a professional designation.
Digitized signatures
An electronic image is an individual’s handwritten signature reproduced in its identical form using a pen tablet.

18. Signature Guidelines Additional Signature Guidelines
CMS MLN Matters article SE1237, “Importance of Preparing/Maintaining Legible Medical Records”: Network-MLN/MLNMattersArticles/Downloads/SE1237.pdf
CMS MLN Matters article MM6698, “Signature Guidelines for Medical Review Purposes”: and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/mm6698.pdf

19. Evaluation & Management Services
E/M Services
Always bill the most appropriate level of E/M services
Upcoding and downcoding are both counted as billing errors
New Patient Visits
Ensure the patient has not been seen by the same specialty within the same practice in the past 3 years.
Know the Guidelines
The 1995 E/M guidelines are more general
The 1997 E/M guidelines provide more specialty-focused direction.
Both sets of guidelines are available on the CMS website
MLN/MLNEdWebGuide/EMDOC.html

20. General rules for Documenting E/M Services
If it isn’t documented, it hasn’t been done.
The medical record should be complete and legible.
The documentation of each patient encounter should include:
Reason for the encounter;
Assessment, clinical impression or diagnosis;
Plan of care;
Legible identity of the observer along with the date of the signature;
This is a common phrase heard in the health care setting. Documentation is an integral part of a patients care. Medical records report the care that a patient received and because of this it is always important to document everything that was involved in the patient’s care.
The reason for the encounter should also include relevant history, physical exam findings and prior diagnostic tests.
Discuss briefly a what is an acceptable signature and provide information where this information can be found.

21. General Rules for Documenting E/M Service
The rationale for ordering diagnostic and other ancillary services should be clearly identifiable in the record;
Health risk factors should be identified;
The patient’s progress, response to and changes in treatment and revision of diagnosis should be documented; and
The information in the medical documentation should support the diagnosis codes billed.

22. Selecting the Appropriate E/M Code
These steps should be taken when selecting an E/M code:
Identify the category or subcategory of the service provided.
Review the reporting instructions for the selected category or subcategory according to the CPT book.
Review the level of E/M service descriptors.
Determine the extent of the history obtained.
Determine the extent of the examination performed.
Determine the complexity of MDM.
Select the appropriate level of E/M service.
For example, is this an office visit, an inpatient hospital visit, a skilled nursing facility visit? Then is the patient a new patient or established patient, is it an initial hospital visit or subsequent. All of these things are factors in determining the correct E/M code.
When coding the service make sure that the code is reasonable for the nature of the presenting problem. Coding should be based on the nature of the presenting problem and the amount of work needed for the problem not the volume of documentation. For example, you probably would not want to bill a for a patient who presented with ear pain and has a diagnosis of otitis media even if the volume of documentation caused the code to score out to that.

23. Insufficient Documentation
Medical necessity must always be clearly documented in the patient’s medical record.
When documentation is requested, remember to send all relevant information, including orders, plans of care, etc.
If documentation is missing a signature, have the provider complete an Attestation Statement, and include it with the documentation.

24. Other Documentation Issues
Scribing:
EHR Cloning:
Amendments/ Corrections to Medical Records:

25. Resources

26. CGS Administrators, LLC.
MR Articles
April 1, 2013
CGS MR Initiatives
Articles on new/ongoing initiatives
Published PCA Results
Articles
KY – CPT code 88305
OH – CPT modifier 25
2013 Therapy Cap Process
KY – New Patient Office Visits
OH – New and established Home Visits
ASC – Claims for Unlisted Codes and Codes Subject to Medical Review
KY – Initial Hospital Care
OH – Chiropractic Services
Scribes
KY – Established Office Visits
KY/OH – Ambulance HCPCS code A0427
Rule-Out Diagnosis Codes
KY – Chiropractic Services
Radiology - Physician / Practitioner Order Required
SE1123
2013 Copyright, CGS Administrators, LLC.

27. CGS Documentation Checklists
The CGS Documentation Checklists are useful tools to assist providers in preparing and submitting documentation.
These checklists will help to guide you with the types of information that should be available in the patient's record.
We have also included important reminders and citations for the recommended components of documentation in each checklist.

28. CGS Documentation Checklists
E/M Services Other Services
CPT code 99205
CPT codes
CPT code 99222
CPT code 99223
CPT code 99232
CPT code 99233
CPT code 99285
CPT codes
Advanced Imaging Services
Ambulance Services
Blepharoplasty
Chiropractic Services
Home Dialysis Visits
Radiation Therapy Services
Outpatient Physician Dialysis Visits
Physical Therapy Services

29. Comparative Billing Reports
CMS authorized SafeGuard Services to produce Comparative Billing Reports (CBRs)
CBRs are documented analysis that shows a provider’s billing patterns and compares that billing to their peers
The purpose of peer comparisons is to allow providers to proactively identify errors in their billing practices
Data also available in the new Interactive Website Map
Sample Topics Include
Physical therapy/KX modifier
Chiropractic services
Ambulance
Podiatry
Sleep studies
Cardiology services
Evaluation & Management Services
Advance diagnostic imaging
Pain management

30. Medicare Quarterly Provider Compliance Newsletter
Addresses common billing errors and other claim review findings
MLN/MLNProducts/ProviderCompliance.html

31. Questions?