Gastroenterology Coding Alert

Gastroenterologists billed $91M in Part B improper payments last year, report says.

If your practice logged 6.2 percent of its claims incorrectly, you’d be out a significant amount of money, right? Unfortunately, that was the case for many GI practices last year, when gastroenterologists submitted over $90 million in improper payments, according to CMS’ latest report.

Background: CMS issued its “2020 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 21 as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found a 6.3 percent improper payment rate (8.1 percent for Part B) among claims submitted during the 12-month period from July 1, 2018 through June 30, 2019.

The good news: Gastroenterologists had a lower improper payment rate than the overall average, and the error rate for this specialty came down from 10.2 percent in last year’s report. However, the goal at your GI practice should be to have no errors, or as close to zero as possible. Therefore, it’s a good idea to see which codes were billed incorrectly so you can tighten up your practice’s coding strategies.

Colonoscopies Responsible for Millions in Improper Payments

Colonoscopy claims were among the Part B services that had the highest error rates, responsible for nearly $23 million in projected improper payments.

Considering that the average colonoscopy reported with the base code 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) pays about $357 in the non-facility setting, it can cost your practice a significant amount of money over the course of a year to forego maintaining accurate documentation for these procedures.

“Filling in the documentation blanks provides a more complete record that is easier to defend against payer scrutiny and denials,” says Terri Tamez, CPC, CEO of Phoenix Coding and Consulting Service. “It also helps the coders give you full credit for the services you provided. Get paid for what you do!”

Not far behind colonoscopies on the list of Part B services with high error rates were upper GI endoscopy procedures, which logged $18.7 million in projected improper payments. Also on the list were echography/ultrasonography procedures of the abdomen and pelvis (responsible for $8.7 million in projected errors).

Insufficient Documentation Among Biggest Issues for GI Practices

When it came to the reasons behind gastroenterologists’ improper payments, insufficient documentation was the biggest culprit, representing over 63 percent of the errors. Close behind was incorrect coding at 30.5 percent.

Remembering that the physician’s documentation is key to supporting every code level is essential. This may be more challenging than ever now that practices are dealing with new E/M coding guidelines that require them to select outpatient E/M codes based on either the total time spent the day of the patient encounter or the medical decision making (MDM).

In addition, Tamez notes, you must document the differential diagnoses that the physician considers which require additional workup or treatment. “Remember, the chart reviewer cannot assume why you ordered certain tests,” she said. “Coders cannot interpret, infer, or imply why any treatment or tests are ordered.”

Check Which E/M Codes Featured the Most Errors

CMS breaks down which codes had the most incorrect coding errors among all Part B providers, with the following among the biggest offenders:

• Established patient office visits. The outpatient established E/M codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …) represented $400.9 million in projected improper payments.
• Initial hospital visits. In the initial hospital visit E/M category (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient …) Medicare made $359.5 million in projected Part B improper payments.
• Subsequent hospital visits. The codes for subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient …) represented $261.6 million in improper payments.
• New patient office visits. Coming in fourth on the list, the new patient E/M codes (99202-99205, Office or other outpatient visit for the evaluation and management of a new patient …) were responsible for $260.6 million in improper payments.
• Hospital visit – critical care. The fifth code series with incorrect coding error involved critical care visits (99291- +99292, (Critical care, evaluation and management of the critically ill or critically injured patient …), logging $146.1 million in projected improper payments.

As most practices are aware, it’s critical to ensure that you’re reporting your E/M services accurately, since these codes represent a major slice of your practice’s income. Particularly in light of the reimbursement losses that many physicians are facing due to the pandemic, you want to hang on to as much of your income as you can, and correct coding is the best way to do that.

Resource: To read the full CERT document, visit www.cms.gov/restricted-access-vbdlvcertreportsdl/2020-medicare-fee-service-supplemental-improper-payment-data.