ED Coding and Reimbursement Alert

Insufficient Documentation

CMS found that the vast majority of improper Medicare payments — 63.1 percent — were due to insufficient documentation. In these situations, the medical records do not substantiate whether the service was medically necessary.

Example: The documentation includes the phrase “ED visit for ear pain.” The record lacks a date of service, an explanation of any exam performed or history of present illness, or any other details. Therefore, the reviewer marks this claim as non-payable since it is lacking even basic documentation to demonstrate anything that the physician did.

Medical Necessity Errors

About 16.2 percent of improper payments outlined in the 2020 report were due to medical necessity errors. In these situations, the patient receives a service or product, but does not have a medical need for it.

Example: The patient from the ear pain example above is found to have a buildup of ear wax. The ED physician bills cerumen removal (69210, Removal impacted cerumen requiring instrumentation, unilateral) and the payer reimburses the charge. However, the subsequent review shows that the physician was simply moving aside ear wax to visualize the eardrum, which is not a covered service billable with 69210 due to a lack of medical necessity.

Incorrect Coding

About 10.9 percent of the improper payments that CMS identified were due to incorrect coding. In these situations, the wrong code was reported for the service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity). The documentation demonstrates a problem-focused history and exam, and the medical decision making is of straightforward complexity, leading the reviewers to downcode this visit to 99281.

No Documentation

Some 4.4 percent of improper payments were attributed to “no documentation” errors. Under these circumstances, the provider either did not document the service at all, could not find the documentation, or simply failed to submit it to reviewers.

Remember the old adage that “if it wasn’t documented, it wasn’t done” – this is how auditors will look at the situation, so you should do the same.

“Other” Errors

Issues that don’t fit into other categories, such as patient ineligibility for benefits, are classified as “other” errors, and these occurred in 5.4 percent of cases, according to the CERT report.