Medicare Compliance & Reimbursement

If the latest CERT report is any indication, you could have made a lot more money last year.

According to the Comprehensive Error Rate Testing (CERT) results that the Centers for Medicare & Medicaid Services (CMS) released in late November, Medicare carriers discovered more than $259 million in undercoding billing errors, which means that medical practices shorted themselves that much last year.

For example, the report highlights a practice that billed 40 units of J1756 (Iron sucrose, 1 mg). CMS discovered, however, that the practice actually injected 200 mg, which would have allowed it to have billed 200 units. That practice shorted itself over $200.

The only non-E/M CPT codes on the list of the top 20 "underpayment coding errors" were 20610 (Major joint aspiration/injection) and 92012 (Eye exam), which puzzled some practices.

General practices are error-prone: Error rates among the different provider types showed that general practices had an alarming 27 percent error rate, with ob-gyns close behind at 24 percent.

The lowest error rates were found in claims from ASCs, CRNAs, interventional radiologists, mass immunizers and public health agencies.

Avoid this $1,000 mistake: The CERT report offers examples of claims that contained errors. For example, one Part B payer reimbursed a physical therapist $1,120, but the claim reviewer couldn't find documentation of the physician's order, therapy evaluation or plan of care, causing the reviewer to count the entire payment as an error.