Evaluate Your E/M Coding, Because Medicare Is On Alert

Posted on 26 Sep, 2015 |comments_icon 2|By Chris Boucher

CMS: Improper E/M coding on the uptick.

Practices that bill Medicare incorrectly create newsworthy events. If you don’t want to see your practice on the front page for the wrong reasons, you’ll need to check your E/M coding conventions to be sure you aren’t miscoding E/M services.

The lowdown: The 2014 Medicare Fee-for-Service improper payment rate was 12.7 percent. This is far worse than the error rates logged in 2012 and 2013, according to the latest Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) report.

Medicare Will Want Refunds

Perhaps unsurprisingly, CMS identified $47.6 billion that went out to Medicare providers in error, and chances are high that Medicare contractors will want that money back.

Most of the E/M coding errors were found in the following areas:

Documentation: For the second year in a row, Part B practices had a significantly higher error rate than Part A providers when it came to insufficient documentation, with Part B facing a 2.1 percent error rate as compared to 0.2 percent in Part A.

Incorrect coding: Part B providers rated the highest among incorrect coding errors, with a 0.8 percent error rate, which topped the Part A and DME rates. Not all of these errors reflected overpayments to practices — in some cases, doctors actually shorted themselves by coding incorrectly.

Non-physician practitioners: The CMS auditors also found a large number of errors among E/M claims performed by non-physician practitioners. “The CERT program identified many improper payments for E/M services billed using physician’s NPIs but provided solely by non-physician practitioners,” the report states. “NPPs must bill under their own NPIs if they provide an E/M service (in person) for a physician’s patient in hospital and the physician does not also perform (and document) a substantive part of an E/M visit face-to-face with the same beneficiary on the same date of service.”

Avoid These E/M Errors, Keep Coding On Track

Often, the coding errors were due to practices submitting documentation that supported a different E/M level than what was billed. Other issues included insufficient documentation, no physician authentication, or wrong place of service.

For example, the CERT reviewers audited one claim for 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) that described a routine follow-up for a stable patient requiring no changes in treatment or medications. The auditors were unable to find justification for 99214, and downcoded the claim, marking it as an incorrect coding error.

To read the complete CERT results, visit www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/MedicareFeeforService2014ImproperPaymentsReport.pdf.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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