Claim Type |
Improper Payment Rate |
Improper Payment Amount |
---|---|---|
Overall |
7.66% |
$31.70 B (Billion) |
General surgery |
4.8% |
$54.4 M (Million) |
Diagnostic radiology |
7.2% |
$264 M |
Resolution |
Resource(s) | |
---|---|---|
Insufficient documentation. Missing order/intent to order. |
Medical records must support treating provider's order for nail care performed in a skilled nursing facility to support debridement of nail(s) by any method(s); six or more. • The order must be dated and must have been issued by the supervising physician prior to mycotic nail debridement services being rendered. • Telephone or verbal orders not written personally by the supervising physician must be authenticated by the dated physician’s signature within a reasonable period of time following issuance of the order. • The order must be consistent with the attending physician’s overall plan of care. • The order must be for medically necessary services to address a specific patient complaint of physical finding. • Routinely issued or “standing” facility orders for mycotic nail debridement services that do not meet the above requirements are insufficient. • Services to residents of nursing homes performed at the request of the patient or patient’s family/conservator should indicate if the request was from the patient or the patient’s family/conservator. • When the request is from someone other than the patient, the documentation should identify the requesting person's relationship to the patient. |
|
Insufficient documentation. |
Medical records must support the neurostimulator implantation services were provided. • Indicate if request is for a trial or permanent placement. • Physician office notes including: • Condition requiring procedure • Physical evaluation • Treatments tried and failed including but are not limited to: • Spine surgery • Physical therapy • Medications • Injections • Psychological therapy • Documentation of appropriate psychological evaluation • For permanent placement, include the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s). • A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications. |
|
Insufficient documentation. |
Medical record documentation to support the medical necessity for cataract removal. Cataract surgery will be considered medically reasonable and necessary when one or more of the following indications are present: • Visual function no longer meets the patient’s needs based on visual acuity, visual impairment, and potential for functional benefits. • Visual Impairment and function are not correctable by glasses or other non-surgical measures. The patient has undergone a preoperative examination that documents the following: • Inability to function satisfactorily due to visual impairment while performing various activities of daily living. • Confirmation that cataract is causing the visual impairment or other ocular or systemic conditions. • Cataract is causing unacceptable glare, polyopia, or reduced quality of vision. • There is clinically significant anisometropia in the presence of a cataract. • The lens opacity interferes with optimal diagnosis or management of posterior segment conditions. • The lens causes inflammation or secondary glaucoma (phacolysis, phaco-anaphylaxis). • There is worsening angle closure (phacomorphic glaucoma) due to increase in size of the crystalline lens. A significant cataract is present in a patient who will be undergoing concurrent surgery in the same eye, such as a trabeculectomy or a corneal transplant when the surgeon deems that the decreased morbidity of single stage surgery is of significant benefit over surgery on separate dates. |
CERT Finding |
Resolution |
Resource(s) |
---|---|---|
Documentation to support medical necessity is inadequate. |
Medical record documentation must include medical necessity for the billed radiology exam. |
|
Insufficient documentation. Missing order. |
Medical records must support treating provider's order for or clinical documentation to support the plan/intent to order diagnostic testing. |