Gastroenterology Coding Alert

Colonoscopies, upper GI procedures appeared to have been error-prone last year.

From colonoscopies to office visits and beyond, GI physicians and coders have myriad rules to follow when selecting the right codes to use. And that could be causing some practices to code incorrectly, if the results of a new report from CMS are any indication.

Background: CMS published its “2021 Medicare Fee-for-Service Supplemental Improper Payment Data” Dec. 7, 2021, 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 among claims submitted during the 12-month period from July 1, 2019 through June 30, 2020. The overall Part B error rate was 8.5 percent.

GI specialists had a higher improper payment rate than the overall average, and the 8.9 percent error rate for this specialty also rose from last year. Although 2021 was certainly a year that presented new challenges, from seeing more patients via telehealth to understanding new E/M rules, physicians are expected to properly document, and your practice is still expected to code and bill specialists’ services properly.

Upper GIs, Colonoscopies Responsible for Millions in Improper Payments

Upper GI endoscopy procedures were high on the list of Part B errors, logging $16.8 million in projected improper payments. Also on the list were echography/ultrasonography procedures of the abdomen and pelvis (responsible for $14.4 million in projected errors).

Not far behind these procedures on the list of Part B services with high error rates were colonoscopy claims, responsible for $3.3 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. Therefore, you should always check the code that the GI physician marks and ensure that the documentation matches the code you’re submitting.

Insufficient Documentation Among Biggest Issues for Gastroenterologists

When it came to the reasons behind gastroenterologists’ improper payments, insufficient documentation was the biggest culprit, representing 75.7 percent of the errors. Close behind was incorrect coding at 20.5 percent.

Remember that the physician’s documentation is key to supporting every code level. 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 with the patient or the medical decision making (MDM) while selecting E/M services for inpatient, ED, and other places of service that still rely on the 1995 and 1997 guidelines.

“Many practices did not realize that changes to patient forms, EHR templates, and manual documentation formats needed to be reworked before the start of last year in order to best support the 2021 E/M guidelines for office and other outpatient services,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. “As a result, the support systems in place for physicians did not adequately provide what they needed to fully take advantage of the ‘Patients over Paperwork Initiative’ and best practices for documenting for the new E/M guidelines.”

Insufficient documentation doesn’t necessarily mean that your practice has lost or truncated its existing documentation — instead, it often means that the provider didn’t document enough in the first place to justify the services you billed.

Example: The physician’s documentation for an E/M service states, “Patient presented to evaluate continuing stomach pain.” The record lacks a date of service, an explanation of any exam performed or history of present illness, and may also be missing many other details. Therefore, the reviewer marks this claim as non-payable since it is lacking even the most basic information that would allow it to qualify for an E/M code (99202-99215).

When it comes to incorrect coding, reviewers note this type of error when you report the wrong code for a service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter) for an office visit with a patient. The documentation indicates that the gastroenterologist only spent 15 minutes with the patient and that the MDM was straightforward. Therefore, the visit is downcoded to 99212 (… straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter).

“Keep in mind that the new E/M guidelines are designed to pay the physicians for their cognitive work applied to the encounter,” Cobuzzi says. “But if the physician does not document their thought process, the diagnoses they are ruling out in addition to the final diagnosis, the plans of care being considered in addition to the final plan of care, and any mitigating factors such as social determinants of health or patient’s refusal to follow the physician’s advice, the auditor will not see what the physician’s cognitive work was during the encounter.” The 2021 E/M guidelines are designed for the physicians to show their work, so that whoever reviews documentation can see everything the physician was thinking and the physician can get credit for everything when determining the E/M level.

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 $722.8 million in projected 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 $498.3 million in 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 $463.9 million in projected Part B improper payments.
• New patient office visits. 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 $256.1 million in improper payments.
• Hospital visit – critical care. Critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …) logged $134.8 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 GI specialists have faced due to the COVID-19 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 https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0.