High Errors Identified for Insufficient Documentation by Renal
Dialysis Facilities (ESRD), Type of Bill (TOB) 72x
The Medicare Fee-for-Service 2014 Improper Payments Report identified service type, Clinic ESRD - TOB 72X, as
one of the highest improper payments for Part A (excluding inpatient hospital PPS). The national report indicated
insufficient documentation errors were 97.4% for the Clinic ESRD service type.
Comprehensive Error Rate Testing (CERT) data also identified significant improper payment errors for insufficient
documentation of ESRD (TOB 72X) services. J10 CERT data has validated that a significant portion of the
improper payments occurring on TOB 72X involved insufficient documentation. The Centers for Medicare &
Medicaid Services (CMS) implemented the CERT program to measure improper payments in the Medicare Fee-forService program.
CERT Errors - ESRD: Insufficient documentation errors included a lack of valid physician dialysis for billed
dates of service, missing medication orders, an outdated physician order; missing laboratory results and accurate
documentation of medication administration; units of medication were coded and billed incorrectly. Specific CERT
errors included:
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Missing the physician's medication orders for Epogen 3800 units (1/15 - 1/22/13) and Zemplar 4 mcg (1/26
- 1/31/13); therefore, the associated syringes were not medically necessary.
No additional documentation to support Venofer given on specific dates.
Missing documentation of Epogen administration on billed dates of service.
Provider billed 163 units of Q4081 (inj., Epoetin Alfa) instead of 180 units.
Medical records lack dialysis treatment records, signed protocol and documentation of medication
administered.
Records were missing a Hemodialysis daily treatment note to support the items and services billed on a
claim.
A dated and signed Hemodialysis order was over 1year old; no response to the CERT request for a current
physician order.
Dialysis treatments, medications, and labs for one month were billed; the physician's signed and dated order
for the dialysis treatment was not in the record.
Lab results were not documented in the medical record.
In some cases, additional documentation was not submitted as requested by the CERT Review Contractor.
Compliance Recommendations: Medical record documentation must be accurate and support reasonable and
medically necessary services. To ensure comprehensive medical records, medical professionals are expected to
accurately document pertinent information in the medical record. Recommendations for accurate documentation of
the errors above include, but are not limited to the following:
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A valid physician order for dialysis services.
A valid physician order for medications (date, signature, dosage/units, and route); specific drug treatment
protocol.
Ensure correct drug units/dosage are accurately administered and documented.
Ensure that all physician orders for Clinic ESRD services are current.
Completely document and include all treatment notes and the medication administration sheet in the record.
Verify correct billing of all services; review units billed to units actually administered and documented.
Submit requested supporting documentation in a timely manner.
Comply with CMS signature requirements
Conduct internal audits of medical records
Detailed education on the importance of a complete ESRD medical record is located in the Code of Federal
Regulations (CFR) Interpretive Guidance §494.170; Subpart D - Administration; Condition: Medical Records. The
CFR excerpt states:
In ESRD, the term “medical records” includes printed or electronic information such as, but not limited to
consents, histories and physicals, medication reports, radiology reports, laboratory reports, dialysis treatment
orders, patient assessments, patient plans of care, treatment records, and progress notes regarding the
condition and care of the patient. Each patient’s medical record, whether hard copy, electronic, or a
combination of both, should include complete and pertinent information about the condition of the patient,
assessments by the interdisciplinary team, updated plans of care, all interventions and treatments prescribed
and delivered, and details of any events occurring with the patient during the course of treatment. No matter
what format, the record of care must be readily accessible to every authorized member of the healthcare team
so that care can be coordinated to best meet the needs of the patient.
The facility must create and maintain a complete and accurate record of care for every patient that is unique
for that patient. Each patient’s medical record should clearly portray the patient, the care provided by the
facility personnel, and the outcomes of that care.
For further education on ESRD medical record documentation, CMS signature requirements and compliance
recommendations, refer to the following resources:
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CMS Guidance: Laws/Regulations Dialysis - ESRD Program Interpretive Guidance - §494.170; Condition:
Medical Records
Comprehensive Error Rate Testing (CERT)
MLN Matters® Number: SE1419 - Medicare Signature Requirements - Educational Resources for Health
Care Professionals
Continued Use of Modifier 59 after January 1, 2015
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare
Administrative Contractors (MACs) and Durable Medical Equipment (DME) MACs for services provided to
Medicare beneficiaries.
What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) implemented Change Request (CR) 8863 on January 5,
2015, effective January 1, 2015. This CR established four (4) new HCPCS modifiers (XE, XP, XS, XU) to define
specific subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service”. These modifiers are
collectively referred to as –X {EPSU} modifiers. Please note that providers may continue to use the -59 modifier
after January 1, 2015, in any instance in which it was correctly used prior to January 1, 2015. The initial CR
establishing the modifiers was designed to inform system developers that healthcare systems would need to
accommodate the new modifiers. Additional guidance and education as to the appropriate use of the new –X
{EPSU} modifiers will be forthcoming as CMS continues to introduce the modifiers in a gradual and controlled
fashion. That guidance will include additional descriptive information about new modifiers. CMS will identify
situations in which a specific –X {EPSU} modifier will be required and will publish specific guidance before
implementing edits or audits.
CR 8863 states that providers who wish to use the new modifiers may use them in accordance with their published
definitions, and the X modifiers will function within CMS systems in the same manner as the 59 modifier, bypassing
Procedure-to-Procedure (PTP) edits with a modifier indicator of “1,” for example. A modifier indicator of “1”
indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances.
Additional Information
CR 8863 is available at http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1422OTN.pdf and a related MLN Matters® article is available
at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM8863.pdf on the CMS website.
Inquiries about CR 8863 (Specific Modifiers for Distinct Procedural Services) and any MLN Matters® article
associated with the new X Modifiers, should be sent to the following email address: NCCIPTPMUE@cms.hhs.gov.
Proper use of the ‘Medicare Treatment Authorization’ Field
Unique Tracking Number (UTN) Field Requirements for Prior Authorization
Starting January5, 2015 claims with data in the Prior Authorization field will be edited for validity. For DDE
submitters and hardcopy claims, the Medicare Treatment Authorization field must contain blanks or valid Medicare
data in the first 14 byes of the treatment authorization field. For electronic claims submitted in the ASC X12 837
format, if the 2300 loop with a REF01 segment value of G1 is submitted, the REF02 must not be equal to blanks and
must be a valid value.
Claims that contain invalid data will be returned to the provider (RTP) with edit 30729 for correction. Valid data for
this field is:
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Unique Tracking Number (UTN) = first two positions of the UTN must be alpha-numeric and not contain
spaces, third position of the UTN must be “A” or “H,” and the last 11 positions must be numeric and not
contain spaces
Trial = 49
SPN66
64
56
A/B REBILLING
54
SPN65
07
08
Valid 18-byte OASIS Treatment Number for Home Health claims.
ICD-10 Volunteer Testing Form - Revised
Effective with dates of service on or after October 1, 2015 the ICD-9 code sets will be replaced by ICD-10 code sets.
To help prepare for this transition, the Centers for Medicare and Medicaid Services (CMS) is soliciting volunteers
to conduct limited end-to-end testing with the Medicare Administrative Contractors (MACs) April 27 through May
1, 2015.
The sample of 50 participants for each MAC will be selected from volunteers to represent a broad cross-section of
provider types, claims types, and submitter types. Selected testers will be notified that they have been selected by
February 13, 2015. Those selected will be provided specific details regarding how to test and who to contact for
testing support.
Submitters who participated in the January 2015 round of end-to-end testing are automatically eligible to participate
in this round, as long as they use the same submitter codes, NPIs, PTANs, and HICNs for their test
claims. Interested providers/organizations must submit a completed form by January 21, 2015.
Ambulance Claim Denials for Invalid Physician Certification Statements
for Nonemergency, Scheduled, Repetitive Ambulance Transports
During a recent medical review audit, claims have been denied for insufficient documentation when the
nonemergency, scheduled, repetitive ambulance transport PCS was signed by anyone other than a
physician. Medical review has identified physician certifications statements for nonemergency, scheduled,
repetitive ambulance transports that are being signed by registered nurses.
The 42 CFR Section 410.40 Coverage of ambulance services (d) (2) Special rule for nonemergency,
scheduled, repetitive ambulance services (i) states, "Medicare covers medically necessary
nonemergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before
furnishing the service to the beneficiary, obtains a written order from the beneficiary's attending physician
certifying that the medical necessity requirements of paragraph (d)(1) of this section are met. The
physician's order must be dated no earlier than 60 days before the date the service is furnished."
The PCS is the written order certifying the medical necessity of nonemergency ambulance transports.
All nonemergency, scheduled, repetitive ambulance transports require a written PCS from the
beneficiary's attending physician. Only a physician may sign the PCS for nonemergency, scheduled,
repetitive ambulance transport. The PCS must be dated no earlier than sixty days before the date the
service is furnished.
A repetitive ambulance service is defined as medically necessary ambulance transportation that are
furnished three or more times during a 10-day period or at least once per week for at least three
weeks
There is no required form or format for the PCS; however, the following information must be available
in the medical documentation:
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Patient's name
Date(s) of ambulance transport
Patient's medical problem/condition necessitating the ambulance transport. Information on the
PCS should include a specific explanation as to why other means of transportation would
endanger the patient's health.
Signature of an authorized individual and the date signed. Note: Medicare requires that
services provided/ordered be authenticated by the author. The signature for each entry must
be legible and should include the practitioner's first and last name. For clarification purposes,
we recommend you include your applicable credentials (e.g., D.O. or M.D.).
There is no specific Medicare-approved form for PCS. As a best practice, most ambulance providers/
suppliers develop a PCS form that contains all the necessary elements required by CMS for a PCS.
Regardless of the form or format you choose to use, the information must comply with Medicare
guidelines.
In all cases, the provider or supplier must keep appropriate documentation on file and, upon request,
present it to the contractor. The presence of the signed physician certification statement does not
alone demonstrate that the ambulance transport was medically necessary. All other program criteria
must be met in order for payment to be made.
Related Content
The regulations governing PCS requirements are specified in the Code of Federal Regulations at 42
CFR 410.40(d). These regulations are the basis for Medicare guidelines.
Anesthesia furnished in conjunction with colonoscopy
Section 4104 of the Affordable Care Act defined the term “preventive services” to include “colorectal cancer
screening tests” and as a result it waives any coinsurance that would otherwise apply under Section 1833(a)(1) of
the Act for screening colonoscopies. In addition, the Affordable Care Act amended Section 1833(b)(1) of the Act to
waive the Part B deductible for screening colonoscopies. These provisions are effective for services furnished on or
after January 1, 2011
In the 2015 PFS Proposed Rule, CMS proposed to revise the definition of “colorectal cancer screening
tests” to include anesthesia separately furnished in conjunction with screening colonoscopies; and in the
2015 PFS Final Rule with comment period, CMS finalized this proposal.
The definition of “colorectal cancer screening tests” includes anesthesia separately furnished in
conjunction with screening colonoscopies in the Medicare regulations at Section 410.37(a)(1)(iii). As a
result, beneficiary coinsurance and deductible does not apply to anesthesia services associated with
screening colonoscopies.
As a result, effective for claims with dates of service on or after January 1, 2015, anesthesia professionals
who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy
(HCPCS code 00810 performed in conjunction with G0105 and G0121) shall include the following on the
claim for the services that qualify for the waiver of coinsurance and deductible:
Modifier 33 – Preventive services: when the primary purpose of the service is the delivery of an
evidence based service in accordance with a USPSTF A or B rating in effect and other preventive
services identified in preventive services mandates (legislative or regulatory), the service may be
identified by adding 33 to the procedure. For separately reported services specifically identified as
preventive, the modifier should not be used.
Additional information
The official instruction, CR 8874 issued to your MAC regarding this change is available at http://www.cms.
gov/Regulations-and-Guidance/Guidance/Transmittals/ Downloads/R3160CP.pdf.
The Centers for Medicare & Medicaid Services (CMS) updated payment rates for travel allowances and
specimen collection fees when billed on a per mileage basis using Health Care Common Procedure
Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for
2015.
Payment of the travel allowance is made only if a specimen collection fee is also payable. The travel
allowance is intended to cover the estimated travel costs of collecting a specimen including the laboratory
technician’s salary and travel expenses. The per mile travel allowance is to be used in situations where
the average trip to the patients’ homes is longer than 20 miles round trip.
The per flat-rate trip basis travel allowance is $10.30.
Further details are available in MLN Matters® article MM9066
.
Modifier look up web site
http://medicare.fcso.com/tools_center/modifier_License.asp
Clinical laboratory fee schedule update on travel allowances and
specimen collection fees
Effective date January 1, 2015
Implementation date: April 24, 2015
Summary
The Centers for Medicare & Medicaid Services (CMS) updated payment rates for travel allowances and
specimen collection fees when billed on a per mileage basis using Health Care Common Procedure
Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for
2015.
Payment of the travel allowance is made only if a specimen collection fee is also payable. The travel
allowance is intended to cover the estimated travel costs of collecting a specimen including the laboratory
technician’s salary and travel expenses. The per mile travel allowance is to be used in situations where
the average trip to the patients’ homes is longer than 20 miles round trip.
The per flat-rate trip basis travel allowance is $10.30.
Further details are available in MLN Matters® article MM9066
Fee schedule look up
http://medicare.fcso.com/Fee_lookup/fee_schedule.asp
.
2015 HCPCS local coverage determination changes
LCD Title
Changes
Alemtuzumab (Campath®)
LCD is being retired based on the OPPS payment
status indicator being changed to an “E” (Not paid by
Medicare when submitted on outpatient claims [any
outpatient bill type]) for HCPCS code J9010
Allergy Testing
Deleted HCPCS code G0461
Added CPT® codes 88341, 88342, and 88344
Descriptor change for CPT® code 84600
Biventricular Pacing/Cardiac
Resynchronization Therapy
Descriptor changes for CPT® codes 33217, 33224,
33225, 33230, 33231, 33240, and 33249
Bone Mineral Density Studies
Deleted CPT® code 77082
Added CPT® codes 77085 and 77086
Colorectal Cancer Screening
Added HCPCS code G0464
Added language pertaining to CPT® code 00810 and
Modifier 33 (Related to change request (CR) 8874)
Revised LCD to re-state the utilization parameters and
ordering requirements (Related to CR 8881)
Diagnostic and Therapeutic
Descriptor change for CPT® codes 43247 and 43250
Esophagogastroduodenoscopy
Diagnostic Colonoscopy
Descriptor change for CPT® codes 44388, 44390,
44391, 44392, 45378, 45379, 45380, 45381, 45382,
45384, 45385, 45386, 45391, and 45392
Deleted CPT® codes 44393, 44397, 45355, 45383,
and 45387
Added HCPCS codes G6019, G6020, G6021, G6024,
and G6025
Added CPT® codes 44401, 44402, 44403, 44404,
44405, 44406, 44407, 44408, 45388, 45389, 45390,
45393, 45398, and 45399
Erythropoiesis Stimulating
Agents
Removed HCPCS code J0890 based on the OPPS
payment status indicator being changed to an E” (Not
paid by Medicare when submitted on outpatient claims
[any outpatient bill type]) and the nationwide recall and
revisions in language were made throughout the LCD
for clarification
Added HCPCS codes J0887 and J0888
Ferrlecit® and Venofer®
Added HCPCS code J1439
Changed LCD Title to Parenteral Iron Supplementation
for Patients Receiving ESA Therapy for Anemia of
Chronic Kidney Disease or Iron Deficiency Anemia
Gene Expression Profiling
Removed unlisted CPT® code 84999 and replaced
Panel for use in the
with CPT® code 81519
Management of Breast Cancer
Treatment
Genetic Testing for Lynch
Syndrome
Deleted HCPCS code G0461 and G0462
Hemophilia Clotting Factors
Descriptor change for HCPCS code J7195
Added CPT® codes 81288, 88341, 88342, and 88344
Deleted HCPCS codes C9133 and C9135
Removed unlisted HCPCS code C9399 and replaced
with HCPCS code C9136
Added HCPCS codes J7200 and J7201
Hyperbaric Oxygen Therapy
(HBO Therapy)
Deleted HCPCS code C1300
Implantable Infusion Pump for
the Treatment of Chronic
Intractable Pain (Coding
Guidelines only)
Deleted HCPCS code J2275
Intensity Modulated Radiation
Therapy (IMRT)
Deleted CPT® codes 0073T, 76950, 77305, 77310
,77315, 77326, 77327, 77328, 77385, 77386, 77387,
77403, 77404, 77406, 77408, 77409, 77411, 77413,
77414, 77416, 77418 , and 77421
Added HCPCS code G0277
Added HCPCS code J2274
Added HCPCS codes G6001, G6002, G6003, G6004,
G6005, G6006, G6007, G6008, G6009, G6010,
G6011, G6012, G6013, G6014, G6015, G6016 and
CPT® codes 77306, 77307, 77316, 77317, and 77318
Mohs Micrographic Surgery
(MMS)
Deleted HCPCS codes G0461 and G0462
Molecular Pathology
Procedures
Descriptor change for CPT® code 81245
Noncovered Services
Deleted CPT® code 0181T (replaced with CPT® code
92145), CPT® code 0199T (replaced with unlisted
CPT® code 95999 – Tremor measurement with
accelerometer(s) and/or gyroscope(s), CPT® code
0226T (replaced with HCPCS code G6027), CPT®
code 0227T (replaced with HCPCS code G6028),
Added CPT® codes 88341, 88342, and 88344
Added CPT® codes 81246, 81288, and 81313
CPT® code 0239T (replaced with CPT® code 93702),
CPT® code 0334T (replaced with CPT® code 27279),
and CPT® codes 87620/87622 (replaced with CPT®
codes 87623,87624, and 87625)
Deleted CPT® code 88349
Paclitaxel (Taxol®)
Deleted HCPCS code J9265
Added HCPCS code J9267
Psychiatric Diagnostic
Deleted HCPCS code M0064
Evaluation and Psychotherapy
Services
Qutenza® (capsaicin) 8%
patch
Deleted HCPCS code J7335
Added HCPCS code J7336
Radiation Therapy for T1
Descriptor change for CPT® code 77401
Basal Cell and Squamous Cell
Deleted CPT® codes 77403, 77404, 77406, 77408,
Carcinomas of the Skin
77409, 77411, 77413, 77414, 77416, and 77418
Added HCPCS codes G6003, G6004, G6005, G6006,
G6007, G6008, G6009, G6010, G6011, G6012,
G6013, G6014, G6015
Screening and Diagnostic
Mammography
Descriptor change for HCPCS codes G0204 and
G0206
Added CPT® code 77063 and HCPCS code G0279
Stereotactic Radiosurgery
(SRS) and Stereotactic Body
Radiation Therapy (SBRT)
Deleted HCPCS codes G0173 and G0251
Transesophageal
Echocardiogram
Added CPT® code 93355
Vertebroplasty, Vertebral
Augmentation; Percutaneous
Deleted CPT® code 22520, 22521, 22522, 22523,
22524, 22525, 72291, and 72292
Added CPT® codes 77372 and 77373
Added CPT® codes 22510, 22511, 22512, 22513,
22514, and 22515
Viscosupplementation Therapy Descriptor change for CPT® codes 20610 and 27370
for Knee
Removed unlisted HCPCS codes C9399/J3490
(Monovisc) and replaced with HCPCS code J7327
Part A Providers
Transition from IACS to EIDM
Effective February 9, 2015, the existing system for controlling access to the PS&R applications hosted by CMS IACS (Individuals Authorized for Access to CMS Computer Systems) - will be replaced by EIDM (Enterprise
Identity Management). Going forward, individuals seeking to create new accounts, manage their existing accounts,
or log into PS&R will no longer use IACS, but will instead use EIDM. Existing IACS accounts will be converted
into EIDM accounts, retaining the existing User ID, password, profile information, and access rights. The login
page and profile management screens will look different, but the functionality provided by EIDM is the same as that
provided by IACS. The address for PS&R at https://psr-ui.cms.hhs.gov/psr-ui will not change as a result of this
transition.
Between January 30 and February 8, please note the following impacts due to the transition from IACS to EIDM:
1. Individuals will be unable to create new IACS accounts for accessing PS&R
2. Changes to existing IACS accounts will be allowed by the system, but none of these changes will be carried
over to the new EIDM accounts (i.e. - Login, Change Password or Personal Information, or add/modify
access to CMS applications, etc...)
3. Migration activities will take place ensuring that users with existing IACS accounts are transitioned over to
the EIDM system
4. Access to PS&R will continue to be available using existing IACS accounts
The exact timeframe during which the PS&R may be inaccessible as part of this transition is still to be
determined. A subsequent communication will be sent once this has been finalized.
While existing IACS accounts will be transitioned over for use in EIDM, security questions and answers currently
established in IACS will NOT be a part of the migration. These questions are currently used to enable expired or
forgotten password resets without having to contact the service desk, EUS (External User Services), for
assistance. Upon successful login to the new EIDM account management system, you will be asked to establish
new security questions and answers.
In light of this, it is strongly encouraged that all PS&R users login to their IACS account prior to January 30, 2015
to change their password (The “Change Password” option can be found at https://idm.cms.hhs.gov/idm/user/). This
will ensure that an individual will not have to contact EUS for assistance with their password change when EIDM is
made available on February 9, 2015.
Note: DO NOT register for a new User ID in EIDM prior to the transition as this will cause complications for your
account.
For any users which have a domain whitelist in place (a list of allowed websites at your worksite), the following
domains need to be added to that whitelist to allow access to EIDM profile management, the application’s new login
screen, etc:
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eidm.cms.gov
portal.cms.gov
If at any point you are in need of support regarding your IACS / EIDM account, please contact EUS using the
following information:
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Telephone: 1-866-484-8049, TTY/TDD 1-866-523-4759
Email: eussupport@cgi.com
Website: https://eus.custhelp.com/
Hours of Operation: 7 a.m. – 7 p.m. ET
Additional information regarding the transition may be posted at CMS’s IACS Information page at
www.cms.gov/IACS.