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August 2007 Client Newsletter


On Friday, August 17th CPB will be closed for the day to enable our staff to enjoy our annual office Employee Appreciation outing.

NPI #’s

CMS is supposed to make the full NPI # list available online for download as a file on August 1st. We have printed the entire list of referring physicians in the CPB database and will begin loading NPI #’s as soon as they are available.

Zostavax – Not Covered By Medicare

The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Part B Medicare coverage [CMS Internet Only Manual publication 100-2, Chapter 15, Section]. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster; and in an immunocompromised state, the vaccine is contraindicated and should not be administered. The vaccine (but not the administration) may be covered under the Part D (prescription drug) Medicare benefit. In such cases it is a non-covered service and can be collected from the patient on the date of service. Posted by CMS on 07/25/2007.


Providers Nationwide recently received requests for charts as part of the Comprehensive Error Rate Testing (CERT) by Medicare. The auditor is independent of all carriers. We are not aware of any CPB clients that received such a request. However, if you received one, be sure to review the records prior to sending them to Medicare. When you do, look at them from the perspective of auditor – is it clear what you wrote? Is it legible and does what was written makes sense? The auditor isn't familiar with the patient or your style of documentation.

Some things the auditor will look for:
-Does the documentation support the services & level of services billed?
-Is the medical necessity for each service clear & concise?
-For those encounters where the key elements in the documentation supported the E/M you billed, was the level of service billed consistent with the nature of the presenting problem in the documentation of that encounter? Or is this a case where there's lots of documentation, but the problem severity isn't articulated in a way that supports the problem?
-Did you bill any procedures? Would someone who knows nothing about you, how you practice, or anything about the patient, be able to say that the documentation of the procedure clearly mapped to the CPT code(s) (and associated modifiers, if applicable) that you billed?
-Was there any part of the encounter that was routine or would otherwise be excluded from Medicare coverage? If so, was it billed to Medicare in a manner to obtain the expected denial?
-If the service you provided is one where the carrier has an NCD or LCD, does the documentation support the diagnosis code(s) you submitted that established medical necessity for claims payment?
-If there was a frequency limitation for the service billed, does the encounter reflect that there was sufficient time since the previous encounter for Medicare to consider this DOS a covered service?

-If there appears to be some gaps in what the auditor needs to know, send a cover letter explaining it for each patient.
-Send the requested information as soon as it is ready and do not miss the deadline. Missing the deadline will raise attention to your audit in unnecessary ways.
-Send it to the address given in the letter – it does not go to the Medicare Carrier for your state.
Be sure to send ALL the requested information. Make sure each page has the patient’s name on it so they cannot get mixed with another patient’s documentation. Each patient’s data should be clipped together neatly. You want that packet of documents to clearly, logically and concisely present the practice's supporting documentation for the encounters under review.
2007 Client Newsletter Archive