Medicare Benefit Policy Manual CHAPTERS 1 -4-6-12

Medicare Benefit Policy ManualCHAPTERS 1 -4-6-12 Chapters Recently Changed

(Rev. 119, 01-15-10) • Medicare Benefit Policy Manual • Chapter 1 - Inpatient Hospital Services • Covered Under Part A • 1 – Definition of Inpatient Hospital Services • 10 - Covered Inpatient Hospital Services Covered Under Part A

(Rev. 1882, 12-21-09) • Medicare Claims Processing Manual • Chapter 4 - Part B Hospital (Including • Inpatient Hospital Part B and OPPS)

(Rev. 116, 12-11-09) • Medicare Benefit Policy Manual • Chapter 6 - Hospital Services Covered Under Part B • Transmittals for Chapter 6 • Crosswalk to Old Manuals • 10 - Medical and Other Health Services Furnished to Inpatients of Participating Hospitals • 20 - Outpatient Hospital Services • 20.1 - Limitation on Coverage of Certain Services Furnished to Hospital Outpatients

(Rev. 1881, 12-18-09) • Medicare Claims Processing Manual • Chapter 12 - Physicians/Nonphysician Practitioners • (Rev. 1843, 10-30-09) • (Rev. 1859, 11-20-09) • (Rev. 1875, 12-14-09) • (Rev. 1881, 12-18-09) • 10 - General • 20 - Medicare Physicians Fee Schedule (MPFS) • 20.1 -

CMS Tightens Documentation and Signature Requirements Impact of More Stringent Review Criteria

Records from the treating physician not submitted or incomplete • In the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then 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.

Missing evidence of the treating physician's intent to order diagnostic tests • 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, including signed orders and/or progress notes.

Medical records from the treating physician did not substantiate what was billed • Again, in the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then 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.

Missing or illegible signatures on medical record documentation • In the past, CERT would 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.

CERT Contractors Advised • CMS has instructed CERT contractors to follow the letter of the law in determining whether a claim has been billed properly and if there is sufficient documentation present to support the need for services. Thus, each claim must stand alone and be supported by documentation clearly showing the intent of the ordering physician and the reasons for ordering the service(s) for that episode of care, with orders that are complete and signed.

Transmittal 327 • Further details related to signatures were published in Transmittal 327 of the Medicare Program Integrity Manual (100-08), released on March 16, 2010. The signature guidelines apply to reviews conducted by Medicare Administrative Contractors (MACs), CERT Contractors and Recovery Audit Contractors (RACs).

No Rubber Stamping • Medicare requires that services provided or ordered be authenticated by the author. The method used for authentication may be a handwritten or electronic signature. Rubber-stamp signatures are not acceptable. • Exceptions are made for certifications of terminal illness for hospice care and orders for clinical diagnostic tests. However, if there is an unsigned order for a clinical diagnostic test, there must be documentation by the physician, such as a progress note, that shows that the physician intended for the test to be performed. This documentation must be authenticated.

Signature authentication process • CMS states that providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead use the signature authentication process. This process requires the author of the order to sign an attestation that he/she is the originator of the order, and does not allow for anyone but the ordering/treating physician to make the attestation. While there is currently no specified format or language for the attestation, a suggestion is included in the transmittal.

Signatures must be complete and legible. If a signature is illegible, there must be a typed or printed name next to the signature. Initials are not acceptable as signatures without further documentation (attestation, signature log, typed or printed name next to the initials, etc.)

To assess the impact of these two documents, providers should conduct their own review of order signatures to see if they meet these new requirements. At the same time, the documentation supporting the services provided should be reviewed to determine if it provides all the information necessary to support medical necessity.

excisional debridement • Here is a simple yet common example of an excisional debridement claim that a RAC determined to be incorrectly coded: • A physician wrote in the medical record that "debridement was performed." • Procedure code 86.22 was assigned by a coder. • A complex review was conducted and the RAC determined that the procedure should have been coded 86.28, because there was no reference to "excisional" and no indication that it was in fact the physician who performed the procedure.

Remember: not documented = not done. • Today, however, a RAC might not make this same decision. According to the rules issued by Coding Clinic in the fourth quarter of 1998, the denial decision was correct, but those rules were superseded by a slightly different set of regulations issued in the second quarter of 2000. By then, CMS decided that excisional debridement could be performed by a nurse, therapist, physician assistant, or a physician. • Nevertheless, the physician still must document "excisional debridement" in the record, or it won't matter. • Remember: not documented = not done.

Simply not enough detail • Also, it is important for physicians to know that simply stating "excisional debridement was performed" is simply not enough detail. Why? Because the definition (in ICD-9-CM Volume 3) of procedure code 86.22 states that it must include "removal by excision of devitalized tissue, slough or necrosis." This can be done by a sharp instrument, or even a laser, however the service must be described further as a cutting away of tissue, not simply the removal or scraping away of loose skin.

In addition, there are some things specifically excluded by the definition: it cannot include debridement of abdominal wall, bone, muscle or nails, nor non-excisionaldebridements, open fracture debridements, or pedicle or flap graft debridements.

Splitting Hairs; Huge Impact • It may seem like CMS is splitting hairs here: after all, the care is being given and we're not even talking about medical necessity, so what's the big deal? What difference does it make? To a patient, perhaps none. To a facility, however, it's HUGE. • Without going into details here, there is a difference that could be as much as $6,600 for a single claim .

Extension Bill Signed • Today, President Obama signed into law the “Continuing Extension Act of 2010” extending the freeze on the Medicare Physician Fee Schedule through May 31, 2010. This temporary postponement prevents physicians from suffering the 21.5% physician cut in Medicare reimbursements that had been in effect since April 1. Effective immediately, CMS will instruct its contractors to submit claims that have been held since April 1 and later for processing and payment.

Congress must continually be encouraged to address the SGR issue to eliminate the ongoing threat of the 21.5% reduction in reimbursement for services to Medicare patients.

Physicians should take the same preventative measures that facilities take against RACs. By making sure the billing is clean, the documentation is in order, and that the bill matches the documentation, this strategy should benefit physicians and prevent audits.

Projected Improper Payments Standard Error • All Provider Types With • Internal Medicine 9.4% $48,653,191 1.4% • Family Practice 8.7% $21,299,713 1.9% • Cardiology 5.7% $21,138,857 1.7% • Orthopedic Surgery 8.4% $12,664,058 3.7% • Pulmonary Disease 9.9% $9,286,467 4.8% • Nephrology 11.4% $9,025,301 7.5% • Emergency Medicine 5.8% $7,090,258 2.0%

All Provider Types 5.1% $210,566,867 • General Surgery 4.8% $5,531,184 2.7% • Ophthalmology 2.5% $4,891,194 2.1% • Urology 3.1% $4,583,069 2.0% • Diagnostic Radiology 2.0% $4,075,457 1.6% • Podiatry 7.2% $4,057,267 2.7% • Hematology/Oncology 1.1% $3,311,955 0.8% • Gastroenterology 2.8% $2,303,952 2.1% • Anesthesiology 2.1% $1,245,543 1.5% • Clinical Laboratory 0.7% $1,089,499 0.4%

Thank You

Medicare Benefit Policy Manual CHAPTERS 1 -4-6-12