Overview
We identified documentation problems with 113 of 180 sampled MassHealth vision care claims that were paid to Dr. Frederick Wagner Jr. Specifically, 704 of these 113 claims lacked documentation indicating the medical reason (chief complaint) for the services provided. For 245 of the 113 claims, Dr. Wagner did not have the required documentation, including evidence of the appropriate type of patient history, examination, and medical decision-making, to substantiate billing using evaluation and management (E/M) codes 99304, 99305, 99306, 99308, 99309, and 99310. The absence of such documentation from MassHealth members’ medical records not only raises concerns about the propriety of the related billings, but also can negatively affect continuity of care for the patient.
We extrapolated the test results related to the lack of a documented chief complaint to the entire population of paid vision care claims. Based on this testing, the actual error rate in our sample was 39%, and when projecting this to the total population of paid vision care claims, we are 95% confident that at least 32.8%, or $286,738, of Dr. Wagner’s claims were overpaid. In addition, we extrapolated the test results related to improperly documented E/M services to the entire population of paid vision care claims. Based on this testing, the actual error rate in our sample was 13%, and when projecting this to the total population of paid vision care claims, we are 95% confident that at least 9%, or $15,198, of Dr. Wagner’s claims were overpaid. In the Office of the State Auditor’s (OSA’s) opinion, the lower limit (the most conservative amount, which is $301,936, the sum of these two projections) is the minimum amount that Dr. Wagner must repay to the Commonwealth.
In addition, for 196 of the 113 claims, the dates of service billed did not match those in the members’ medical records. If the date of service is wrong, members might incorrectly be denied services for which they are eligible, or a provider might be paid for services that were not eligible for reimbursement; such overpayments could have been allocated to Medicaid or other state benefit programs.
We also noted that 84% of our sampled members had diagnoses such as Alzheimer’s disease, dementia, or schizophrenia. These vulnerable populations of MassHealth members are often poorly served and unable to advocate for themselves. Because these members might not be able to provide a complete verbal medical history, it is imperative that Dr. Wagner maintain adequate documentation in order to maintain continuity of care for them. In addition, the lack of documentation calls into question whether some of these services were actually necessary.
Authoritative Guidance
The Centers for Medicare & Medicaid Services’ (CMS’s) 1997 Documentation Guidelines for Evaluation and Management Services defines a chief complaint as follows:
A concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words.
These guidelines also require that medical records clearly reflect the patient’s chief complaint.
MassHealth’s regulations give specific details regarding what should be included in medical records. Section 433.409(D)(1) of Title 130 of the Code of Massachusetts Regulations (CMR) states,
Medical records . . . must include the reason for the visit and the data upon which the diagnostic impression or statement of the member’s problem is based, and must be sufficient to justify any further diagnostic procedures, treatments, and recommendations for return visits or referrals. Specifically, these medical records must include, but may not be limited to, the following: . . .
(e) the diagnosis or chief complaint.
Further, according to 130 CMR 450.205(A), MassHealth requires providers to clearly document the medical reason (chief complaint) for the services:
The MassHealth agency 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 to, or prescribed for, members.
The American Medical Association’s Current Procedural Terminology Professional Edition 2014 and CMS’s Documentation Guidelines for Evaluation and Management Services provide guidance on billing for E/M services: physicians should use the billing code that best reflects the level of service provided based on three key components (the complexity of medical decision-making, type of exam, and patient history).
Regarding billing using E/M procedure codes, 101 CMR 315 provides a detailed description of each code. Below is a table indicating the E/M codes Dr. Wagner used.
|
Procedure Code |
New or Established Patient |
Type of History/Exam |
Complexity of Medical Decision-Making |
Number of Components Needed |
Minutes Spent with Patient |
|---|---|---|---|---|---|
|
99304 |
New |
Detailed or Comprehensive |
Straightforward or Low |
3/3 |
25 |
|
99305 |
New |
Comprehensive |
Moderate |
3/3 |
35 |
|
99306 |
New |
Comprehensive |
High |
3/3 |
45 |
|
99308 |
Established |
Expanded |
Low |
2/3 |
15 |
|
99309 |
Established |
Detailed |
Moderate |
2/3 |
25 |
|
99310 |
Established |
Comprehensive |
High |
2/3 |
35 |
Unacceptable billing practices are explained in 130 CMR 450.307:
(A) No provider may claim payment in a way that may result in payment that exceeds the maximum allowable amount payable for such service under the applicable payment method.
(B) Without limiting the generality of 130 CMR 450.307(A), the following billing practices are forbidden: . . .(2) overstating or misrepresenting services.
Finally, according to 130 CMR 450.231(B), providers are required to bill MassHealth with the proper date of service, which the regulation defines as “the date on which a medical service is provided to a member.”
Reasons for Inadequate Documentation
Dr. Wagner stated that each component (including medical history, examination, and medical decision-making) is clearly included in his medical record. He said that he documents patients’ medical history, the result of his medical exam, and his medical decision-making by recording his findings, recommendations, and/or proposed plan of care in their medical records. Although we did find some evidence of these components in members’ medical records, it was not adequate to support the level of E/M service billed.
Dr. Wagner also stated that he begins filling out documentation for a MassHealth member’s exam, including the date of service and other member information, before visiting the nursing facility. He said that if he does not perform the services as anticipated because the MassHealth member is ill or he does not have enough time, he returns on another day to perform the service but does not update the date of service in the documentation.
Recommendations
- Dr. Wagner should collaborate with MassHealth to repay the $301,936 discussed in this finding.
- Dr. Wagner should document the chief complaint or reasons for the services provided in members’ medical records.
- Dr. Wagner should properly document the required patient medical history, as well as details about the exam and medical decision-making, when billing for vision care using E/M codes; otherwise, he should bill using eye exam codes.
- Dr. Wagner should submit claims to MassHealth using the actual dates on which the vision care is provided to members.
Auditee’s Response
On Dr. Wagner’s behalf, his legal counsel provided the following written response, dated June 28, 2019, and supporting documentation where indicated in the response:
A. Dr. Wagner’s Standard Medical Record Form Has Consistently Included Documentation of the “Chief Complaint”
The [report] properly quotes the definition of the term “chief complaint” as set forth in the Current Procedural Terminology (“CPT”) Code published by the American Medical Association. Specifically, the CPT Code states that the “chief complaint” is:
A concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words. . . .
The chief complaint is a short statement of the reason why the health care provider is seeing the patient on the date of the visit. Such documentation is included in every one of Dr. Wagner’s medical records. . . . The medical records speak for themselves, and consistently document the reason why Dr. Wagner is seeing the patient. . . . Dr. Wagner has developed—and over time refined—a standard form of medical record that helps ensure that he captures all of the documentation requirements imposed by MassHealth and other payors. Since we received the spreadsheet identifying which claims the audit team believed lacked a chief complaint, Dr. Wagner has been able to locate the records for 27 of . . . 31 encounters, and we are attaching copies of those records. . . . On each of the attached records you will see that there [is] either a reported problem, such as “decreased coordination,” “blurred vision,” “fall,” and “accident right eye,” or an underlying diagnosis, such as “cataracts,” “diabetes,” “high blood pressure,” and “pseudoaphakia,” that is documented as the medical reason for the visit.
As is plain from the very definition cited by the [report], the chief complaint does not need to be an actual “complaint” stated by the patient, and it is not uncommon for Dr. Wagner to see patients who do not have sufficient mental capacity to seek out his care. As the [report] notes, 84% of the patients in the audit sample “had a diagnosis such as Alzheimer’s disease, dementia, or schizophrenia.” . . . Such patients very often are unable to articulate their need for a visit with an optometrist. Accordingly, it is common that the reason for Dr. Wagner’s visit is the patient’s current eye diagnosis or a request from a physician or nurse at the facility that the patient’s vision be evaluated. These all fall within the definition of chief complaint cited above. When a nurse or doctor’s request is the basis for the visit, Dr. Wagner always documents who made the request. . . .
B. Lack of a “Chief Complaint” Is Not a Basis for MassHealth to Deny Payment
Although Dr. Wagner denies the conclusion that his medical records lack documentation of a chief complaint, it should be noted that MassHealth regulations do not mandate this for reimbursement. Instead, as the [report] itself states, MassHealth regulations require that the medical record include “the diagnosis or chief complaint.” . . . Accordingly, MassHealth regulations are satisfied if Dr. Wagner documents the chief complaint or the pertinent medical diagnosis. . . . Dr. Wagner also routinely documents the patient’s pertinent medical diagnoses.
C. Dr. Wagner’s Documentation Supports the Evaluation and Management Codes He Used
Dr. Wagner’s medical records appropriately document the required elements of medical history, examination, decision-making, and proposed plan of care. [Attached are examples.] Dr. Wagner is unable to more specifically respond to this finding . . . as the report does not discuss what the Auditor’s Office found to be lacking for any particular patient. It does not even offer a single patient example, instead simply states that while the audit team found some of the needed components in the medical records, the documentation “was not adequate to support the level of E/M service billed.” . . . Based on this broad, conclusory statement, it is unknowable what the audit team found lacking in any particular encounter.
It is also unclear what standard the audit team applied to determine whether the proper E/M code was used. In explaining its understanding of E/M coding . . . the [report] only lists the components required for a “comprehensive evaluation” and erroneously states that a comprehensive history, a comprehensive exam, and high-complexity decision-making are required for 99306, 99308, and 99310. . . . This is incorrect. . . .
Only 99306 requires a comprehensive history, a comprehensive exam, and high complexity decision-making. Moreover, all of the subsequent visit codes only require two of the three listed elements. For example, the 25 claims reviewed that were coded as 99309 only required documentation of two of the following three: (1) a detailed interval history, (2) a detailed exam, and (3) medical decision making of moderate complexity. Additionally, the [report] cites to codes 92002, 92004, 92012, and 92014 as codes available to Dr. Wagner. However, the Vision Care manual makes clear that these four codes are to be used by optometrists working from their own office. Dr. Wagner does not see his patients in his own office; he sees patients in nursing homes. . . .
D. The [Report] Erroneously Finds Transportation Claims Were Miscoded
After the Draft Report was provided, I requested the detail showing which specific claims the audit team had found to be miscoded and why. In response I received a summary spreadsheet that showed which of five potential “errors” each of the reviewed claims was found to have suffered. The chart includes 80 claims for transportation costs, which are coded as T2002. Of those 80 claims, the chart asserts that 39 fail to document a chief complaint and 67 fail to properly document the E/M code. This is nonsensical. The Vision Care Manual establishes that T2002 is properly billed “once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom vision care services were provided out of the office.” There is no requirement for a chief complaint or for an E/M code for T2002. Accordingly, none of the T2002 codes were erroneously paid on the basis that they lacked either a chief complaint or proper E/M coding.
E. Concerns Regarding Extrapolation Methodology
We have not received adequate information about the extrapolation methodology to determine whether it was properly carried out. As an initial matter, we were not provided any information detailing how the 180 sample claims were chosen, so we have no way to ensure that they were randomly selected. More importantly, given the errors noted above regarding the transportation claims, we are concerned that these were incorrectly included in the extrapolation leading to an exaggerated “error rate” for the consultations and examinations.
MassHealth’s Response
In this case, MassHealth previously identified a number of potential issues with this provider through an internal audit, and in May 2017, MassHealth referred the information it had gathered to the OSA so that the OSA could pursue the case further through this audit. MassHealth appreciates the OSA’s collaboration in this matter and generally agrees with the OSA’s findings, which are consistent with MassHealth’s initial concerns. MassHealth will recoup overpayments from Dr. Wagner as a result of the audit findings. . . .
1. Consistent with MassHealth’s identification of similar issues with Dr. Wagner and referral of this matter to the OSA, MassHealth agrees with the OSA’s finding that Dr. Wagner should repay MassHealth the [$301,936] in identified overpayments.
2. MassHealth agrees with the OSA’s finding that Dr. Wagner must document the chief complaint or reasons for the services provided in the members’ medical records in accordance with 130 CMR 402.417 and 130 CMR 450.205.
3. MassHealth agrees with the OSA’s finding that Dr. Wagner must properly document the required patient medical history in accordance with 130 CMR 402.417 and 130 CMR 450.205, as well as details about the exam and medical decision-making, when billing for vision care using evaluation and management codes.
4. MassHealth agrees with the OSA’s finding that Dr. Wagner must submit claims to MassHealth using the actual dates on which the vision care is provided to members.
Auditor’s Reply
As noted above, CMS guidelines define a chief complaint as follows:
A concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words.
Despite the assertion of Dr. Wagner’s legal counsel, our review of a sample of Dr. Wagner’s medical records showed that for 70 of the 180 claims we reviewed, the corresponding patient records did not contain the details necessary to clearly articulate the medical necessity of the services provided. Specifically, in each of these 70 instances, Dr. Wagner did not provide any type of statement or description that explains the reason he provided vision care services or the reason for the encounter, in either his or the member’s own words. Rather, he simply listed the member’s eye care history as the reason for the visit. We reviewed the documentation Dr. Wagner provided regarding the 27 patient encounters in which he asserts that he adequately documented the chief complaint and found that although he included keywords like “cataracts” or “high blood pressure,” there is no documented description of why the services were necessary. As stated above, Dr. Wagner simply provided the member’s vision care history as the reason for the visit. It is especially important to document the reason for a visit to a member in a nursing home, because such services are unallowable unless the nursing home specifically requests the doctor’s services and that is clearly documented in the member’s record at the facility.
Dr. Wagner’s legal counsel also states that the chief complaint does not always have to be in the patient’s words and that it was common for Dr. Wagner to receive a request from a physician or nurse at a facility to evaluate a patient’s vision. For 59 out of the 70 claims where we found problems, Dr. Wagner did record a physician’s or nurse’s name on the documentation he provided to us; however, there was no documented reason that his services were requested. During our audit, OSA spoke with staff members at 40 of the nursing facilities Dr. Wagner visited, and staff members at the majority of these facilities told us that Dr. Wagner routinely came to their facility every six months unrequested and saw all of the Medicaid patients there. Further, officials at these facilities could not provide us with any documentation to substantiate that the facilities had requested any of the services related to the claims in our sample; therefore, Dr. Wagner was not entitled to be paid by MassHealth for these services under 130 CMR 402.418(B),7 which states the following about services performed outside a provider’s office:
Nursing Facility. The MassHealth agency pays an optometrist or an ophthalmologist for performing an eye examination for a member residing in a nursing facility only when the optometrist or ophthalmologist is specifically requested to do so by the medical director, the nursing director, or responsible staff member at the facility, or by the member's personal physician. The request must be documented in the member's record at the facility. [Emphasis added.]
Of particular concern is that some of the documentation Dr. Wagner provided to us did not match the documentation maintained by the facility. For example, in at least one instance, Dr. Wagner’s documentation included the name of a referring physician, but the documentation maintained by the facility did not indicate that the member had been referred by a physician or other healthcare provider for vision care.
In addition, although Dr. Wagner’s legal counsel asserts that “Lack of a ‘Chief Complaint’ Is Not a Basis for MassHealth to Deny Payment,” 130 CMR 450.205(A) states that MassHealth will not pay a provider who does not document the reason for a service:
The MassHealth agency 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 to, or prescribed for, members [i.e., their chief complaint]. [Emphasis added.]
Despite what Dr. Wagner’s legal counsel asserts, our audit found that for 24 of the 180 sampled claims, Dr. Wagner did not have the required documentation to substantiate billing using E/M codes 99304, 99305, 99306, 99308, 99309, and 99310. Such documentation would have included evidence of the appropriate type of patient history, examination, and medical decision-making—the three components required to bill for E/M codes above low-complexity decision-making. We reviewed the provided documentation related to the 25 medical records billed under code 99309 and still conclude that they do not include a detailed interval history, a detailed exam, or medical decision-making of moderate complexity. The “Authoritative Guidance” section above presents the specific definitions of each E/M code, as documented in 101 CMR 315, for each code billed by Dr. Wagner during our audit period, and this was the standard that OSA used in conducting this analysis. This matches Dr. Wagner’s response about the definition of E/M codes, specifically 99306. We reviewed the three medical records provided by Dr. Wagner related to the claims billed using codes 99309, 99305, and 99306, but they do not include the required documentation, including evidence of appropriate history, examination, or medical decision-making.
Although Dr. Wagner’s legal counsel states that MassHealth does not allow the use of procedure codes 92002, 92004, 92012, and 92014 for nursing home visits, Dr. Wagner used those codes to bill for both Medicaid and Medicare services he provided to MassHealth members living in nursing homes during our audit period.
The audit sampling method OSA used to select and extrapolate our sample to obtain our results is clearly described in the “Audit Objectives, Scope, and Methodology” section of this report and is based on sound statistical sampling techniques. OSA will share this information with MassHealth and Dr. Wagner in the process of resolving the issues identified in this report. Dr. Wagner’s legal counsel also questions our inclusion of transportation claims (service code T2002) in the extrapolation. OSA adjusted the overpayment to exclude transportation costs related to visits for which E/M codes were not properly documented. However, our overpayment calculation does include transportation claims related to visits that lacked a documented chief complaint, because Dr. Wagner should not have billed for travel if there was not a reason for the visit.
Lastly, Dr. Wagner’s legal counsel questions the method of projecting the overpayment and whether the sample was in fact random. In conducting our sampling, OSA used RAT-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 software determines a statistically appropriate sample, giving consideration to the total size of the population, expected error rate, confidence level, and desired precision, which are defined in the “Audit Objectives, Scope, and Methodology” section of this report. RAT-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. Once the sample size was determined, OSA used Audit Command Language, which is a data analysis software program recognized statewide, to select a random sample of claims paid to Dr. Wagner. OSA’s sampling method was sound and consistent with applicable professional standards.
Dr. Wagner’s legal counsel did not provide comments regarding Dr. Wagner billing for the wrong dates of service.
| Date published: | September 24, 2019 |
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