Dig into the 2018 CERT Report for Valuable Lessons to Improve Your 2019 Reporting

Posted on 6 Mar, 2019 |comments_icon 0|By Elizabeth Debeasi

Don’t let top claim errors for your specialty sink your bottom line this year.

With so many coding rules and compliance regulations to follow, it’s easy to lose sight of correct coding and billing from time to time. That appears to have been the case in 2018.

While the Medicare Fee-for-Service (FFS) improper payment rate dropped from 9.51 percent in 2017 to 8.12 percent in 2018, improper payments for Medicare claims during FY 2018 still cost CMS an astronomical $31.6 billion.

What does this disturbing federal price tag mean for your practice? As you might expect from previous years, CMS will heighten scrutiny in 2019, which could mean a spike in claim denials if you neglect to tackle problematic trends in your reporting.

Let’s look at some of the most pervasive issues identified in the 2018 Comprehensive Error Rate Testing (CERT) report to help you pin down your vulnerabilities and keep your claims on track for a profitable year ahead.

E/M Claims Remain Troublesome Across Specialties

If E/M services are the bread-and-butter of your Part B pay, you may want to double-check your reporting for errors, as E/M claims accounted for a whopping 11.9 percent of the overall 2018 improper payment rate.

Payback demands could be forthcoming, given that CMS improperly paid more than $3.8 billion to providers for prominent CPT® codes, according to Table K1 of the CERT report.

Here’s a breakdown of the top three E/M codes causing the biggest problems:

1. 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity…) ranks first on the CERT report’s E/M worries. With an improper payment rate of 27.2 percent, this confusing CPT® code accounted for 1.4 percent of the overall error rate and more than $456 million in improper payments.

2. 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 …) took the second spot with an error rate of 4.8 percent and an overall impact of 1.2 percent. This popular E/M office visit code was improperly paid to the tune of $389 million.

3. 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …), the number one E/M issue in 2017, was bumped down to third for 2018, and contributed to 1.1 percent of the overall error rate with an individual code error rate of 19.1 percent. Issues with 99233 contributed to $365 million in improper payments.

Pulmonology Visits Tallied Millions in Part B Errors

On the list of the specialties with the most Part B improper payments, CMS ranks pulmonologists high, logging a 10.3 percent overall improper payment rate, totaling over $128 million in reimbursement improperly paid. Incorrect coding accounted for 55 percent of those errors.

Subsequent hospital care services were responsible for some $44 million in improper payments. Only four other specialties (internal medicine, family practice, cardiology, and psychiatry) logged higher improper payment amounts for subsequent hospital care.

Tighten Your Subsequent Visit Coding

If you suspect you aren’t coding subsequent hospital visits accurately, you should perform a chart review. Take a random chart sampling, and on each file, determine the history, exam, and medical decision-making (MDM) levels, then select which code your documentation supports.

Caution: Make sure you know the components of each code level (99231-99233) so you can select the right code based on the documentation.

If your physicians discount the value of such a review, you should place the number of visits they undercoded into a graphic format to show them how much money they left on the table. If the opposite is found, then share the amount with the doctors and tell them that they must return that amount back to the MAC due to overpayments.

Ob-Gyn E/M Issues Include Undercoding

On the list of services with the most Part B improper payments, CMS reports ob-gyn visits logged a 7.7 percent error rate, totaling over $42 million in improper payments. This ranks the ob-gyn visit error rate just under the overall Part B error rate of 8.1 percent.

Focus on your coding accuracy and supporting documentation for the following services:

  • Established office visits: 66.4 percent incorrect coding error rate and 24.5 percent insufficient documentation error rate
  • Initial hospital visits: 66.4 percent incorrect coding error rate and 30.3 percent insufficient documentation error rate
  • Subsequent hospital visits: 48.4 percent incorrect coding error rate and 41.3 percent insufficient documentation error rate

Major problems: Non-Medicare fee schedule lab tests, non-Medicare fee schedule minor procedures, and the “other specialty” category were all hit with over a 90 percent insufficient documentation rate.

Note: Ob-gyn lab claims logged a 24.9 percent error rate.

Watch for These Errors

Approximately $214 million in Part B payments were incorrectly paid due to upcoding errors. CERT calculated a particularly high overpayment rate of 15.9 percent for initial hospital visits.

But many of the errors for ob-gyn involved undercoding and reimbursement shortfalls adding up to $13 million for office/outpatient visits. Code 99212 (Office or other outpatient visit for the evaluation and management of an established patient…) alone had a 22.2 percent underpayment rate.

Are You Downcoding Office Visits?

Check out these quick tips to ensure that you aren’t shorting your ob-gyn’s income.

  • Tip 1: Remember than when billing this level 2 established patient service, the ob-gyn is focusing on a single issue.
  • Tip 2: That single issue is minor, or it is following up with the patient regarding conditions that are either now under control or require no more follow-up.
  • Tip 3: This level of service is not normally appropriate for evaluating new presenting problems or problems that continue to require monitoring.
  • Tip 4: However, it is the documentation that is essential here in raising the level of service above that required for a level 2 visit.

Gastroenterology Coding Errors Include High-frequency Service Claims

GI practices incurred 10.6 percent provider compliance improper payment rate and a 5.7 percent overall improper payment rate, totaling over $79 million in improper payments. The majority of those errors (68 percent) were due to incorrect coding, while another 32 percent occurred because of insufficient documentation.

Gastroenterologists lost roughly $202 million in underpaid visits coded as 99213, as well as another $87 million for visits coded as 99212.

On the flip side, some $356 million in Part B payments for 99214 were marked as overpayments, logging a 4.4 percent overpayment rate for this code.

Caution: CMS reported that nearly $6.5 million in Part B claims were improperly paid for upper GI endoscopy. In addition, CMS marked another $6.4 million in improper payments for lab services by gastroenterologists.

And the Nation’s Highest DME Improper Payment Rate Goes to …

No one ever said that coding for eye care is easy — and that seems to have been proven in 2018, as optometry practices top the list of specialties with the most improper DMEPOS payments.

The startling 92.3 percent improper payment rate, racking up more than $18 million in inappropriate payments, was mostly due to insufficient documentation.

If you’re an optometry practice reporting items like post-cataract excision glasses and contacts to your DME supplier, you’ll want to make sure you have the following checklist items on-hand. These are from DME MAC Noridian:

  • A dispensing order, detailed written order, beneficiary authorization, and proof of delivery
  • Medical records showing that refractive lenses are necessary for vision restoration due to pseudophakia, aphakia, or congenital aphakia
  • If using anti-reflective coating, tints, or oversize lenses, the treating physician must document an individualized explanation of medical necessity in the record
  • If using lenses made of polycarbonate or other impact-resistant materials, the record must support that the patient has functional vision in just one eye
  • Use the KX modifier if you report V2750, V2744, V2745, V2780, or V2784, but only if the items meet the medical necessity criteria.

Contributing Editors: Kristin Webb-Hollering, Torrey Kim, and Suzanne Burmeister

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Elizabeth Debeasi
Marketing Writer/ Editor

Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of Telehealth services.

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