Gastroenterology Coding Alert

Gastroenterologists billed $116 million in improper payments last year, report says.

If your practice logged a 10.2 percent coding error rate, that would be cause for alarm, right? Unfortunately, that was the case for many GI practices last year, when gastroenterologists submitted over $116 million in improper payments, according to the latest report from CMS.

The backstory: CMS issued its “2019 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 18 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 an 8.6 percent improper payment rate among Part B claims submitted during the 12-month period from July 1, 2017 through June 30, 2018.

GI Visits Logged Millions in Part B Errors

On the list of the specialties with the most Part B improper payments, CMS ranks gastroenterologists high, logging an 18.8 percent provider compliance improper payment rate and a 10.2 percent overall improper payment rate, totaling over $116 million in improper payments. In addition, CMS found that among Part B claims, upper GI endoscopy procedures were responsible for $9.1 million in improper payments, and colonoscopies represented $64 million in improper payments.

Avoid These Common Errors

Colonoscopy claims were among the types of services that had the highest percentage of “no documentation” issues, meaning that providers either did not document the service at all, could not find the documentation, or simply failed to submit it to reviewers.

“Unfortunately, the old rule of ‘If it was documented, it wasn’t done’ has not changed when it comes to compliant billing and continues to be the root of most of the lost opportunities we see,” says Elaine Dunn, DHA, RRT, RPSGT, CPCO, vice president of revenue integrity and centralized coding with Change Healthcare in Alpharetta, Georgia. “In practice, as we are reviewing the charts, experience will tell us what the clinical sequelae likely was, but all that matters when it comes to assigning a CPT^® code is the documentation that is present to support that code.”

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 $340 in the nonfacility 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!”

Resource: To read the full CERT document, visit cms.hhs.gov/cert and click “CERT Reports” on the left side of the page. From there, you can download the 2019 report.

Don’t Ignore CERT Record Requests

If you receive a medical record request as part of the government’s Comprehensive Error Rate Testing (CERT) program, you should never ignore it. Instead, respond with your records within the timeline that the auditor requests.

During these reviews, the CERT contractor is checking on the accuracy of how CMS contractors are processing claims, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “And when providers actually send in documentation, or show that documentation supported the service, there is no ‘error’ counted. The largest reasons for ‘errors’ is lack of response to CERT letters, thus CERT doesn’t see the documentation and judges the service in question was never done. CMS contractors WANT you to respond to CERT inquiries; it helps them when you can defend your claim.”

The letter from CMS regarding a CERT review will outline the documentation you must submit, as well as information on when and where to submit the information. “Include any additional material that you believe supports the service(s) billed to the Medicare program,” CMS says in MLN Matters article SE0526.

If you happen to notice that the request letter has an inaccurate phone number or address listed for your practice, correct that immediately so you can hear from the requester swiftly and respond in a timely manner, CMS notes. “Remember that physicians, providers, and suppliers do not need to obtain additional beneficiary authorization to forward medical records to the designated CERT contractor,” CMS adds.

If you do not return documentation immediately, you will receive telephone contacts and letters about every 10 to 15 days for approximately 75 days. If you don’t respond by the 75th day, the claim in question will be cancelled and any Medicare pay will be recouped.