Coding Cues: Answers to your questions about...

March 7, 2008

A CERT audit; New NPI mandate; PQRI 2008

Key Points

A CERT audit

Recently our hospital underwent a Comprehensive Error Rate Testing (CERT) audit, in which a CMS reviewer audited inpatient records, including some of mine. I have since been notified that because there were no records found for 25 percent of my billed visits, I owe Medicare an enormous amount of money. I have no control over how the hospital manages its records or which ones were requested and produced. Does CMS have the authority to do this and, if so, what should I do?

The CERT program produces national, contractor-specific, and service-specific error rates for paid claims, as well as a provider compliance error rate-a measure of the extent to which providers are submitting claims correctly. The program uses audit contractors to review representative random samples of both paid and denied Medicare claims to check for accuracy. So, yes, CMS can use the findings to bill individual physicians.

Your attorney may recommend hiring a certified coder to re-audit the records reviewed by the CMS contractor if levels of service were determined to be different than those for which you billed-and independently attempt to find the missing records. If you choose that route, be sure to use a coder who's familiar with your specialty.

Finally, keep the CMS representative who signed the notice you received apprised of the path you're pursuing. If you can prove that the missing records do, in fact, exist and that the documentation supports the level of care you billed for, you should be able to resolve the overpayment charges.

New NPI mandate

CMS recently alerted us that we need to start billing Medicare using our National Provider Identifier. We're already doing this because we've been under the impression that this has been a requirement for some time. Can you clarify?

Until March 1 of this year, use of the NPI was encouraged but not mandated. Since then, Medicare fee-for-service claims must include an NPI in the primary provider fields (billing, pay-to provider, and rendering provider). You may submit NPI/legacy pairs in these provider fields or submit only your NPI, but if the NPI isn't included, the claim will be rejected. There's no such mandate for the secondary provider fields.

PQRI 2008

We didn't participate in the Physician Quality Reporting Initiative for 2007, but would like to do so this year. Where can we find reliable information about the changes in codes and reporting measures that took effect in January 2008, and how to use them?

You'll find several links to helpful resources at the CMS website ( http://www.cms.hhs.gov/pqri) and on the websites of local carriers. In addition, many medical societies publish lists of the ICD-9, CPT, and Category II codes used in reporting measures for the specialties they represent.