Medicare Compliance & Reimbursement

If your favorite code is 99205, watch out. A new Centers for Medicare & Medicaid Services (CMS) report reveals that nearly 25 percent of claims submitted to Part B for this code last year were upcoded.

CMS' Comprehensive Error Rate Testing (CERT) program reviewed claims submitted between April 1, 2006, and March 31, 2007, and released the results last week.

The most frequently upcoded E/M code was 99310 (Subsequent nursing facility care), which had a 26.3 percent error rate. Code 99205 (New patient visit) came in a close second, followed by 99204 (New patient visit) with a 21 percent error rate, 99255 (Inpatient consult) with a 19 percent error rate, and 99245 (Outpatient consult) with an 18.8 percent error rate.

Undercoding also evaluated: Not all physicians billing Part B were upcoding. The CERT results demonstrated that nearly 10 percent of claims for 99241 were undercoded, noting that the documentation for these claims supported higher codes.

Document those 99211 claims: The CERT report also found that 12 percent of claims for 99211 were insufficiently documented. "This is actually not surprising," Rogers says. "Staff members may think that 99211 is simple to document, so they just write down a quick note saying something like 'BP check,' which isn't going to cut it by Medicare's documentation standards."

Despite the startling numbers, however, CMS found that improper Medicare claim payments declined from 14.2 percent in 1996 to just 3.9 percent in 2007, which shows proof that coders have been tightening up their accuracy.

To read Medicare's CERT results in their entirety, visit http://www.cms.hhs.gov/CERT.