CERT review reveals insufficient documentation of arthroscopic rotator cuff repair

A Comprehensive Error Rate Testing (CERT) study showed insufficient documentation causes most improper payments for arthroscopic rotator cuff repairs, according to the October 2017 Medicare Quarterly Compliance Newsletter.

CERT reviewed claims billed with HCPCS code 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair) submitted from January through March 2016. An arthroscopic rotator cuff repair is a procedure involving surgical re-attachment of the tendon to the head of the upper arm bone. 

CERT reported a variety of insufficiencies in documentation for these claims, including:

• lack of physician’s signature, or signature attestation, on a procedure note or diagnostic report
• lack of supporting documentation for the medical necessity of the procedure
• no procedure note

CERT provided an example of a physician asked by a CERT contractor for documentation when billing for HCPCS code 29827. The physician submitted the following:

• signed operative report
• signed pre-operative history and physical for medical clearance prior to surgery

CERT reported that a medical reviewer requested additional documentation but received none from the physician. The submitted records were insufficient to support medical necessity for the billed procedure. Some examples of documentation to support medical necessity include:

• failed conservative treatments prior to the procedure
• preoperative surgeon notes
• signed and dated diagnostic imaging reports

As a result of insufficient documentation, the medical reviewer scored the claim as an insufficient documentation error and the MAC recovered payment from the provider.

For more information, see the Medicare Benefit Policy Manual, Chapter 15, Section 10, on physician services or read the Medicare Quarterly Compliance Newsletter.