News: CERT review shows insufficient documentation for facet joint injections

A Comprehensive Error Rate Testing (CERT) study showed insufficient documentation caused the most improper payments for facet joint injections, according to the January 2016 Medicare Quarterly Compliance Newsletter, Just Coding reported.

CERT reviewed claims billed with HCPCS code 64635 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single facet joint) submitted from July through September 2015. A facet joint injection is a procedure using an imaging-assisted local injection and denervation technique. 

CERT reported a variety of insufficiencies in documentation for these claims, including:

• Lack of a valid physician order with a physician signature or date
• Lack of documentation adequately describing the service defined by HCPCS code or modifier
• No documentation supporting medical need for the procedure
• No physician signature on procedure notes, diagnostic reports, or progress notes
• No preoperative surgeon’s office notes
• No procedure notes
• No submitted signature log or attestation
• Valid ICD-9-CM codes reported, but they alone are not sufficient documentation

CERT provided an example of a physician asked by a CERT contractor for documentation when billing for HCPCS code 64636. The physician submitted the following:

• A consent form
• A procedure note from the date of service
• A progress note from the date of service without indication that a conservative treatment was tried and failed

CERT reported that a medical reviewer requested additional documentation, and the provider sent duplicate documentation back. This documentation failed to meet the Local Coverage Determination (LCD) requirements for these services, which includes:

• An initial evaluation from the physician summarizing diagnostic tests or procedures which justified the presence of facet joint pain
• Any documentation ruling out another etiology for the symptoms
• Documentation showing the patient failed conservative treatment before the facet joint injection was administered

As a result of the insufficient documentation, payment was recouped.

Editor Note: This article originally appeared in Just Coding. To read the full original article, click here.