CERT Reviews; New CPT Modifier; Medicare Visit Reviews

CERT reviews

Q: My office manager is telling me that the rules have changed about carrier reviews, as things have gotten harder in terms of what a payer will look at or consider. Does my EHR office note have to contain everything?

A: What she may be talking about are the CERT reviews - Comprehensive Error Rate Testing. These rules became more stringent back in 2009. In several areas the review rules have tightened:

•CERT used to apply clinical review judgment in considering medical record entries with missing or illegible signatures. Now, CERT disallows entries if a signature is missing or illegible.

• In the past CERT would consider an unsigned requisition or physicians' signatures on test results. Now, CERT requires evidence of the treating physician's intent to order tests, e.g., signed orders and progress notes.

•Previously, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, and apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

New CPT modifier

Q: Is there a new modifier for CPT in 2011?

A: The 2011 AMA CPT book does not contain a new modifier. However, at the CPT Symposium the AMA did announce a new modifier -33 - that is to be appended to the new preventive service codes G0438 and G0439.

Medicare visit reviews

Q: The rumble around the physician's lounge is that Medicare is now requiring that you send in the note for all 99204 and 99205 visits in order to be paid. Can they do that? How do they do that?

A: This could be true depending what state you are in. Highmark in New Jersey sent out a notice that they would be requiring pre-payment review of all 99204 and 99205s due to a 73 percent error rate on review. Even commercial carriers do this from time to time to motivate providers to bolster their supporting documentation. In the case of Highmark, they found deficiencies in the comprehensive history and exam areas on these higher level new patient codes. It is somewhat surprising that they did not mention decision making on the 99205s as that can be difficult to master. The history and physical exam issues are likely more of a housekeeping variety.

You could also be hearing about what has been dubbed "ask first, pay later." Beginning in 2011, new legislation requires CMS to change their methodology of paying claims first and doing reviews later - also called "pay and chase" - and adopt billing software designed with predictive modeling capabilities. So there is the answer to whether they can do that. How they do it? It has to be manual, so you are in the hands of auditors. As to the local issue, if it applies in your state it is likely limited in duration - it must be expensive and these types of reviews are typically short-lived, unless the results and subsequent downgrading of claims outweigh the cost.

New meaning of "fraud"

Q: Did the definition of healthcare fraud change?

A: The short answer is yes. The Federal Enforcement Recovery Act (FERA) was signed into law last year and removes the requirement of intent from the definition of fraud. Under the False Claims Act (FCA) it has always been illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Under the civil FCA, no specific intent to defraud is required. The civil FCA defines "knowing" to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information.

And it's not just about your knowledge of coding and billing. The FCA contains a whistleblower provision that allows a private individual to file a lawsuit on behalf of the United States and entitles that whistleblower to a percentage of any recoveries. Whistleblowers could be current or ex-business partners, hospital or office staff, patients, or competitors.

There also is a criminal FCA. Criminal penalties for submitting false claims can include imprisonment and criminal fines. Physicians have gone to prison for submitting false healthcare claims. The Office of the Inspector General (OIG) also may impose administrative civil monetary penalties for false or fraudulent claims.

Modifier 59 clarification

Q: Has there been a change in the definition of modifier 59?

A: There is some evidence that Medicare and the AMA have changed the way they view modifier 59. This may fall short of a documented change in the way claims are currently adjudicated relative to 59, but comments have been made by sources close to the AMA that seem to change the traditional understanding of this modifier.

There has been no change in the definition of either modifier 51 or 59 in the 2011 CPT manual, but maybe there needs to be. The definition for modifier 59 states that it may be used for "procedures or services not normally reported together" and states that the documentation must support a "…different procedure or surgery, different site or organ system, separate incision/excision, separate lesion," etc. For most of us, and for many years, this was taken quite literally, such that separate lesions excised would be reported with the primary code alone, followed by the additional lesion removal coded with a 59. The same would hold true for different surgeries in different sites.

If I were to code for excision of a 2 cm malignant lesion from the arm, for example, and then the excision of a 2 cm malignant lesion from the neck, I would use the excision codes representing the removals from each of those anatomic sites and put a 59 on the second one. That is what CPT says to do.

Now we are hearing that modifier 59 was only ever intended for use on codes that are bundled by NCCI edits - and that if there is no edit, you shouldn't use modifier 59. Medicare is well within its rights to make such a policy if it so desires, and the AMA could support it if it chose to. But if this is the case, then the CPT manual should make this clear. And it's unlikely that such a decision would go unchallenged by specialty associations. In the lesion excision example I gave above, there are no column one and two edits on the excision codes - so this more recent discussion suggests that I would only be paid 50 percent for the second lesion.

We'll keep you posted on this topic.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the February 2011 issue of Physicians Practice.