Biggest Error in Medicare Claims
for Bariatric Surgery
The Center for Medicare and Medicaid Services (CMS) processes over 1 billion claims from more than 1 million providers, including hospitals, physicians, clinical laboratories and others. Due to this high volume, CMS does not provide precertification for services provided.
CMS attempts to prevent and recover improper payments via multiple auditors; Medicare Administrative Contractors (MACS), Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as the Office of Inspector General.
CMS publishes a quarterly provider compliance newsletter to explain the findings and analysis of its auditors. A CERT review of bariatric surgery was included in the
The cause for the vast majority (98%) of improper payments was insufficient documentation -- something was missing from the medical records. For example, there was:
- No physician’s signature on the procedure note;
- No signature log or attestation submitted;
- Missing documentation on BMI greater than 35;
- Missing documentation of at least one comorbidity;
- Missing documentation of prior failure for medical treatment of obesity; and/or
- Documentation that did not meet the requirements of the National Coverage Determination, Local Coverage Determinations, and/or Articles.
The following examples were provided in the newsletter:
Example 1: Insufficient Documentation for Laparoscopic Gastric Bypass/Roux-en-Y A physician billed for a laparoscopic gastric bypass/roux-en-Y. The medical records received included an unauthenticated copy of the operative report for the billed date of service. The CERT reviewer requested additional documentation from the billing provider and received physician's notes spanning eleven months of care, with a note showing failed medical management for a morbidly obese patient with worsening health conditions. The physician's notes show a BMI of 50.4 on the day of surgery and a BMI of 44 three months post-operatively. No attestation was received for the unsigned operative report. This claim was scored as an insufficient documentation error and the MAC recouped the payment from
Example 2: Insufficient Documentation for Adjustable Gastric Banding A physician billed for an adjustable gastric banding. The CERT reviewer received an operative note and pathology report. However, the treating physician's clinical documentation of beneficiary's BMI, co-morbid conditions related to obesity and documentation of previously unsuccessful medical treatment for obesity were missing. Submitted documentation was insufficient to support service billed per Medicare requirements. Additional documentation was requested but none was received. This claim was scored as an insufficient documentation error and the MAC recouped the payment from the provider.
As bariatric surgery is covered by Local Coverage Decision (LCD) specific to each CMS region, it is important to be familiar with your region’s specific requirements and address them in the submitted documentation. LCD’s can be located here: http://www.cms.gov/medicare-coverage-database/