Gastroenterology Coding Alert

Gastroenterologists also saw high error rates for subsequent hospital visits.

Gastroenterology practices are almost certain to report upper GI endoscopy (EGD) codes on a weekly basis, but just because you report these codes frequently doesn't mean you're reporting them correctly. That's the takeaway from a recent Medicare report, which states that 9.1 percent of EGD claims submitted to Part B payers were paid improperly, representing over $36 million to the Medicare program.

The backstory: CMS issued its "2017 Medicare Fee-for-Service Supplemental Improper Payment Data" in December 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 10.2 percent improper payment rate among Part B claims during 2017, with the majority of those being classified as overpayments to providers.

Gastroenterology Visits Logged Millions in Part B Errors

The government's CERT auditors found other problems beyond the EGD claims that were paid improperly. Following is a list of issues that CMS discovered in its audit of gastroenterology claims:

Don't Fall Into These Traps

Keep in mind that although CMS identified 12.4 percent of gastroenterologists' subsequent hospital visits as improper payments, that doesn't mean that these were all overpayments. Some may have been insufficiently documented to justify the code level submitted, some (typical of past CERT reviews) just reflected failure to submit documentation, while others may have been undercoded.

No matter what your most pressing subsequent hospital code issues are, following five quick steps can help you get your coding in line.

Step 1: Memorize Hospital Coding Levels

Although many consultants will advise practices to review all physician documentation to evaluate whether the right level is being billed, that's not necessarily the first step you should follow. If you and your gastroenterology practitioners don't know what constitutes each service level, reviewing the documentation won't help.

Therefore, you should educate your clinicians regarding what CMS and CPT^® require for each care level.

You can use the following basic guidelines for the three subsequent hospital care levels as a good starting point for physician education. The following codes apply to subsequent hospital care, along with the requirements for each code:

• 99231 -  ... A problem focused interval history; A problem focused examination; medical decision making that is straightforward or of low complexity ...
• 99232 - ... An expanded problem focused interval history; An expanded problem focused examination; medical decision making of moderate complexity ...
• 99233 - ... A detailed interval history; A detailed examination; medical decision making of high complexity ...

Remember: You need two of the three key E/M components (history, exam, and/or medical decision-making) to report subsequent hospital care services. So if your doctor records a problem-focused interval history but an expanded problem-focused exam and moderate complexity medical decision-making (MDM), you can report 99232 since both the exam and MDM meet the requirements for this code.

Step 2: Don't Undercode on Purpose

If your practice routinely reports 99231 for all subsequent hospital care services, tell your physicians that this might raise red flags with your payer. Contrary to popular belief, coding 99231 across the board will not exempt you from a government audit.

For example, a payer may identify your practice for "poor quality of care" because you consistently report low-level codes. If you submit only 99231, the payer may interpret that as saying all hospital patients, regardless of their conditions, receive only a problem-focused history and exam. This can indicate to insurers that your physicians never take a detailed history or exam, or that patients appear to be so stable that the justification for a follow-up visit may come intoquestion.

Step 3: Pull Charts to Find Issues

If your practice routinely reports the same code over and over, or if you simply suspect that you aren't coding subsequent hospital visits accurately, you should perform a chart review. Take a random chart sampling, and on each file you should determine the history, exam, and medical decision-making (MDM) levels, then determine which code the documentation supports.

You may be surprised what you find. "Patient feeling OK today" does not even support 99231 - but some coders have reported seeing documentation as sparse as this in physicians' notes during subsequent visits.

Tactic:  If the physicians fail to see the importance of such a review, you should place the number of visits they undercoded into a graphic format to show them how much money they left on the table.

Keep in mind, however, that if your internal audit reveals a pattern of inappropriate billing, for which funds were received that weren't substantiated by documentation, the practice is under legal obligation with potential of steep penalties (and risk of whistle-blower actions) if the inappropriate payments aren't returned within 60 days of becoming aware of the overpayment.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2017-Medicare-FFS-Improper-Payment.pdf.