Dr. Berman Had Inadequate Documentation to Support Billing MassHealth for at Least $176,737 in Evaluation and Management Services.

Audit calls on Dr. Berman to repay MassHealth for claims that lacked required documentation.

Overview

Dr. Berman did not have the required documentation to substantiate the level of evaluation and management (E/M) services she provided to MassHealth members when using E/M code 99214. We reviewed a statistical sample of 129 out of 8,882 claims, totaling $484,449, that Dr. Berman billed using the E/M code 99214 from January 1, 2015 through December 31, 2016.⁷ Dr. Berman used the 99214 E/M code for all 129 claims, but she did not document the required detailed medical history and detailed medical examination for any of them, and she could not substantiate that members’ services had the level of complexity at which they were billed. Therefore, she received overpayments totaling approximately $176,737 from MassHealth during the audit period.

In further support of our conclusion, during our audit we asked a certified professional coder⁸ at MassHealth to review information about 15 out of the 129 claims in our statistical sample, and for all 15, the coder agreed with OSA’s determination that the E/M services would have been more appropriately billed using procedure code 99213 rather than procedure code 99214.

Authoritative Guidance

According to 130 CMR 450.205(A), to be paid by MassHealth, providers must maintain proper documentation supporting the services billed:

[MassHealth] will not pay a provider for services if the provider does not have adequate documentation to substantiate the provision of services payable under MassHealth. All providers must keep such records, including medical records, as are necessary to disclose fully the extent and medical necessity of services provided.

Additionally, 101 CMR 317.04⁹ lists the required documentation for procedure code 99214:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

These documentation requirements for procedure code 99214 are also in the 1997 Centers for Medicare and Medicaid Services (CMS) document Documentation Guidelines for Evaluation and Management Services.

Reasons for Lack of Proper Documentation

Dr. Berman stated that she believes her documentation for these services complied with the requirements for billing under procedure code 99214.

Recommendations

1. Dr. Berman should repay MassHealth the $176,737 that we identified as lacking the required documentation.
2. In the future, Dr. Berman should maintain proper documentation to support services billed.

MassHealth’s Response

MassHealth agrees with this finding, and notes that the sample of Dr. Berman’s records reviewed by MassHealth at the request of [OSA] supports this finding. MassHealth will recover any overpayments related to this finding after the auditor’s final report has been issued. . . .

MassHealth agrees [that Dr. Berman should maintain proper documentation to support services billed].

Auditee’s Response

Counsel for Dr. Berman objects to the sampling performed by the OSA for this finding. The OSA stated the following for Finding 3: “We reviewed a statistical sample of 129 claims out of 8,882 claims, totaling $176,737, that Dr. Berman billed using the E/M code 99214 from January 1, 2015 through December 21, 2016.” However, 129 claims out of 8,882 claims represents only 1.45% of the claims; 1.45% is not a statistically significant percentage. It is misleading to characterize the findings in this manner.

Counsel for Dr. Berman also objects to the inclusion of a determination by a “Certified Professional Coder” [at MassHealth] regarding 15 of the 129 claims sampled. By including this information, the Office of the State Auditor intentionally misleads the reader into believing that Dr. Berman’s documentation was insufficient for billed E/M claims. However, 15 claims out of 8,882 claims represents only 0.001% of all of the claims of the audit period. This “Certified Professional Coder’s” opinion is based on a statistically insignificant number of claims, and therefore should not be included in this report. While this information should not be included in the final report, if the Office of the State Auditor insists on including this information in the final report, the Office of the State Auditor must include more information on the individual identified as “a Certified Professional Coder,” including a [curriculum vitae] of his/her credentials so that expert status can be ascertained objectively.

Counsel for Dr. Berman would like to indicate that they and Dr. Berman were misled when inquiring about whether this audit would be independent. While the representatives from the Office of the State Auditor were conducting the informal exit conference interview of Dr. Berman, they overtly held themselves out to be an independent entity separate from MassHealth, in so much as stating that their office was separate from MassHealth. However, the use of MassHealth’s own “Certified Professional Coder” . . . directly contradicts the statement that the two entities are independent of one another. . . .

Dr. Berman has provided E/M services that qualified for CPT Code 99214 because she typically documented the detailed medical examination and medical decision making of moderate to high complexity as required by the 1997 CMS Guidelines for E/M Services. In order for a provider to bill CPT Code 99214, a provider must document 2 out of 3 of the following: a detailed history, detailed examination, and/or medical decision making of moderate to high complexity. Dr. Berman bills her E/M services using the 1997 CMS Guidelines for E/M services. The E/M services Dr. Berman provided qualified for the codes billed. The patients to whom Dr. Berman provided services required at least moderate clinical decision making because the patients had at least some of the following: 1) have at least 2 two chronic diagnoses, 2) require ordering and reviewing of tests, 3) require prescription of medication, and 4) need coordination of care with other providers. . . . See 1997 Evaluation and Management Guidelines, 43–47. All of the mental health examinations that Dr. Berman bills under CPT Code 99214 are detailed, including at least 9 elements required by CMS criteria for detailed examination. See 1997 Evaluation and Management Guidelines, 37–38.

Since Dr. Berman hired counsel in April 2018, Dr. Berman has been taking steps to adjust her documentation to better reflect the complexity of the patient care she performed for services billed at CPT Code 99214. While Dr. Berman’s claims previously qualified for CPT Code 99214, her new documentation format will better reflect the complexity of the services as required by the E/M Services guidelines.

Auditor’s Reply

As noted above, for our testing of E/M claims billed by Dr. Berman during our audit period, we reviewed a statistical sample of claims that totaled $484,449, not the $176,737 that Dr. Berman’s legal counsel cites in her response. In conducting our sampling in this area, OSA used RATS-STATS, a statistical sampling program created by the Office of Audit Services within the US Office of Inspector General, in the US Department of Health and Human Services. This sampling software determines a statistically appropriate sample, giving consideration to the total size of the population, expected error rate,¹⁰ confidence level,¹¹ and desired precision.¹² RATS-STATS is widely used by audit agencies and is recognized by MassHealth as the sampling software of choice for evaluating provider claims using a statistical sampling method.

OSA is independent of MassHealth; in fact, MassHealth is one of our auditees. In addition, Section 6.41 of GAO’s Government Auditing Standards states that in certain situations, auditors may determine that it is necessary to use the work of a specialist. During our audit, OSA determined that MassHealth’s coder had the expertise necessary to provide a secondary level of review of claims that OSA was questioning. Before accepting the coder’s assistance, OSA in accordance with generally accepted government auditing standards, documented the coder’s qualifications and assessed their independence. 

During our review of the medical records of the members in question, there was no evidence that Dr. Berman documented a detailed history or conducted a detailed medical examination at the time of their visit. Such an examination would include recording vital signs such as heart rate, blood pressure, body temperature, or respiratory rate; recording prescriptions ordered; and recording and reviewing drug test results. As discussed above, when billing for services using E/M code 99214, providers must document both a medical examination and a detailed medical history, and Dr. Berman did not do so. Therefore, she received overpayments totaling approximately $176,737 from MassHealth during the audit period for the services discussed in this finding.

7.    We chose to review only claims from 2015 and 2016, because Dr. Berman could not locate most of the documentation for these services from 2014.

8.    A certified professional coder is certified in medical coding by the American Academy of Professional Coders.

9.    The quoted version of the regulation was in effect from August 2017 through March 2018.

10.    Expected error rate is the anticipated rate of occurrence of the error of improper billing for services.

11.    Desired precision is a measure of how precise the actual error rate is.

12.    Confidence level is the numerical measure of how confident one can be that the sample results reflect the results that would have been obtained if the entire population had been tested.

Date published:	November 14, 2018