EM Coding Alert

CMS report points finger at insufficient documentation, incorrect coding.

If you’ve ever coded 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date …), you might want to pay attention to the January 2019 Quarterly Compliance Newsletter:

That’s because this latest CMS report has noted some real problems in the way the code has been reported in the recent past, including insufficient or missing documentation and incorrect coding.

So, what’s going on? We took a closer look at CMS’s findings, and here’s what we found.

Background:  When patients are under observation care for a period that spans between eight and 24 hours and are discharged on the same calendar date, you’ll pick a code from the 99234-99236 range, which includes the admission and discharge. In this situation, the documentation must meet the following three requirements according to the CMS report:

• Documentation noting that the stay for observation care or inpatient hospital care involves a period between eight and 24 hours
• A notation that the billing physician was present and personally performed the services
• Documentation identifying that the order for observation services, progress notes, and discharge notes were written by the billing physician.

What the CERT Reviewers Discovered

Reviewers from CMS’ CERT team looked at claims for 99234 that were submitted to Part B MACs between April and June of 2017. They found that many records were missing documentation that would support 99234, and in most cases, the claims were missing one or more of the following:

• A valid physician’s order that includes all required elements.
• Documentation to support the services were provided or other documentation necessary to support the code reported.
• Hospital record.
• A properly authenticated record. If a signature is missing or illegible, a signature log is required.

Check this $135 mistake: Suppose the physician reports 99234. The CERT reviewer contacts the ED and asks for documentation of the observation visit. In response, the ED submits a discharge summary note for the date of service, as well as a history and physical note for the billed date of service, and a physician’s signature.

Although this sounds like sufficient documentation, the CERT reviewer marks it as having insufficient records, and the ED has to return the $135 payment.

Why? The documentation does not have a record of a physician order for observation services, which Medicare requires. This demonstrates that if even one aspect of the requirements cannot be located, Medicare can deny the entire claim, and your provider will have to repay the money.

Some Improper Payments Were Due to Incorrect Coding

Not every error that the CERT reviewers found stemmed from missing documentation – some errors were due to incorrect coding.

For instance:  The physician submits a claim for 99234 and the CERT reviewer requests documentation, which shows that the physician performed a comprehensive history and exam, along with moderate-complexity medical decision making.

In this example, the reviewer found that the claim should have been coded as 99235 instead of 99234, and the ED is able to collect an additional $37, which is the difference between payment for 99234 and 99235.

Resource: To read the entire Medicare Quarterly Compliance Newsletter with the findings about observation care, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-MLN5862089.pdf.