Guest Post: OIG report says CMS should use its own data to target trouble documentation

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

As CDI specialists, we find ourselves trying to keep the attention of our physician audience. The ability to positively engage the physician depends on continually illuminating the direct correlation between accurate and complete clinical documentation and the ongoing evolution of the business of the practice of medicine.

I call your attention to an October report from the Office of the Inspector General (OIG), Center for Medicare and

Medicaid Services’ Use of Medicare Fee-For-Service Error Rate Data to Identify And Focus On Error-Prone Providers, which essentially found that CMS did not use data from its historical Hospital Payment Monitoring Program (HPMP) and Comprehensive Error Rate Testing (CERT) Program  to identify and focus on providers with the highest rates of mistakes.

HPMP, now part of the CERT program, is charged to measure, monitor, and reduce the incidence of improper fee-for-service inpatient acute care Medicare payments by conducting reviews of inpatient admissions to validate accuracy of code and MS-DRG assignment in addition to issuing determinations of medical necessity. The CERT contractor has assumed responsibilities for inpatient record review for calculating the national fee-for-service Medicare payment error rate.

CMS established the CERT program to calculate a national claims error rate for the entire Medicare Fee-For-Service program. The CERT program calculates the error rates for all Medicare Administrative Contractors (MACs) and, until the transition to MACs is completed, the CERT program will also report on carriers, and fiscal intermediaries (FIs). The CERT:

• Randomly selects a sample of approximately 100,000 claims submitted to carriers, FIs, and MACs during each reporting period
• Requests medical records from the healthcare providers that submitted the claims in the sample
• Reviews the claims in the sample and the associated medical records to see if the claims complied with Medicare coverage, coding, and billing rules, and, if not, assigns errors to the claims
• Classifies cases as a ‘no documentation claim’ counting it as an error where medical records are not submitted by the provider
• Sends providers overpayment letters/notices or makes adjustments for claims that were overpaid or underpaid

The CERT program began in 1996. It reports a national paid claims error rate which is based on dollars paid after the Medicare contractor made its payment decision on the claim. This rate includes fully denied claims. The paid claims error rate is the percentage of total dollars that all Medicare FFS contractors erroneously paid or denied. It is a good indicator of how claim errors in the Medicare FFS Program affect the Medicare trust fund. For fiscal year 2009, the national paid claims error rate was 7.8% equating to $24.1 billion.

The CERT program cannot be considered a measure of the cost of healthcare fraud, however. Since the CERT Program uses random samples to select claims, reviewers are often unable to see provider billing patterns that indicate potential fraud when making payment determinations. The CERT program does not, and cannot, label a claim fraudulent.

This last point of identifying individual physician practice patterns of improper physician claims submission was at the gist of the objectives of this OIG review.

The OIG wanted to find out to what extent CMS and its contractors used HPMP and CERT data between fiscal year 2005 and 2008 to identify error-prone providers and initiate corrective actions to address patterns of improper coding and claims submissions.

This OIG examined CERT and HPMP results between 2205-2008 and identified 740 error-prone providers—providers that had at least one claims error in each of the four years of the audit period. Its analysis of the HPMP error rate data showed 554 providers (21% of all HPMP providers with at least one claim sampled in each of the four years) accounted for 59% of the dollars in error for those providers. A similar analysis of the CERT error rate data for the same period disclosed that 186 providers (1.81% of all CERT providers with at least one claim sampled in each of the four years) accounted for 25% of the dollars in error for those providers.

Findings of the OIG Review

The report illustrates, perhaps not surprisingly, that CMS and its contractors did not use historical HPMP and CERT error rate data to identify and focus on error-prone providers. Although payment contractors developed corrective actions based on the HPMP and CERT error rate data, they typically did not focus on error-prone providers for review and corrective action. The report concluded that focusing on error-prone providers for corrective action and repayment of improper payments could improve the effectiveness of CMS’s efforts to reduce improper payments and achieve the CMS goal of reducing improper payments by 50% by 2012.

For CDI specialists, it is important to note that the report mentions the importance of educating physicians on their responsibilities in submitting accurate claims to Medicare—records supported by clear and concise clinical documentation in the record, regardless of provider setting.

According to the report, providers caused most claims errors. Here are some of the findings:

• “Provider actions caused most of the $44.1 billion in improper payments that CMS reported for FYs 2005 through 2008. CMS reported four categories of errors: incorrect coding, medically unnecessary services, documentation errors, and other errors.
• Individual providers are responsible for ensuring that their claims are properly coded and that the care provided is medically necessary and adequately documented.”

The message we should convey to physicians in our daily routine of chart review and identification of opportunities for clinical documentation clarification is the necessity for complete, accurate , specific and detailed clinical documentation in support of patient acuity, severity of illness, risk of morbidity and mortality, acuity risk adjustment, appropriate resource consumption in ordering of diagnostic tests and execution of treatment plans, clinical judgment and physician medical decision-making.

An accurate and true representation of all of these elements consistently included in the physician’s documentation is considered the premise of and foundation for ensuring that the physician’s claims are properly assigned an evaluation and management (E/M) code and that the care provided is substantiated as medically necessary.

As CDI specialists, how often do we note absence of clinical diagnoses in the history and physical (H/P), progress notes, consult reports and notes, and discharge summary? How often do we see documentation in the progress notes stating “continue same treatment” with no indication of what the treatment is? How frequently do we struggle with absence of documentation in the record that demonstrates how the physician addressed the patient’s chief complaint? How often is there simply no documentation of chief complaint, lack of evidence of a physician face-to-face encounter with the patient, or documentation of a list of established diagnoses or potential diagnoses without additional indications(s) in the record of meaningful and necessary evaluation and management for each problem?

Often we do not even see documentation of relevant impressions, tentative diagnoses, confirmed diagnoses and all therapeutic options chosen related to every problem for which evaluation and management is clearly demonstrated. Lastly, how often do we see a series of tests ordered by the physician without clear documentation of the clinical rationale for the ordering of the diagnostic test.

Best practice is for the physician to clearly and explicitly document the association between the diagnostic test and the diagnoses or potential diagnoses. To this end, the physician will be providing a road map of his thought processes, clinical judgment and medical decision making in demonstration of medical necessity from a hospital as well as physician E/M assignment, quality of care, and efficiency perspective.

OIG’s recommendations

The OIG recommended that CMS:

• Use available error rate data to identify error-prone providers
• Require error-prone providers to identify the root causes of claim errors and to develop and implement corrective action plans
• Monitor provider-specific corrective action plans
• Share error rate data with its contractors (QIOs, RACs, and PSCs) to assist in identifying improper payments

In its response to the report, CMS agreed to conduct analysis of historical error rate data similar to the 2010 analysis beginning with FY 2009 data and share the findings with the appropriate contractors to assist in developing corrective actions. CMS also said it would direct its contractors to initiate appropriate administrative actions for providers determined to be error prone. Furthermore, CMS pointed out there are other administrative actions it can take, such as probe reviews and individualized education for problematic providers.

The real message we need to carry to our physicians is that the increased scrutiny of their E/M documentation is a reality. They should consider clinical documentation an integral component their physician services vital to maintaining financial viability in the business of medicine, particularly given the role of accurate and complete clinical documentation in the transition to healthcare delivery reform provisions.

Being labeled as an “error prone” provider by Medicare invites increased scrutiny, potential prepayment reviews, potential financial recoupments, and increased administrative work for the physician’s practice. Our efforts at affecting positive change in physician documentation patterns must incorporate the concept of the physician “getting it right the first time” with adequate documentation to support the amount of work performed, clinical medical decision-making and medical necessity for amount of work performed while adhering to official E/M documentation guidelines.

Let the fun begin!

Editor's note: Krauss, at the time of this article's release, was Executive Director of the Foundation for Physician Documentation Integrity.