Medicare Compliance & Reimbursement

Lack of medical necessity and lax coding round out the top 3 reasons.

For FY 2018, CMS uncovered $31.6 billion in improper payments. The agency broke down the claims and coding issues into categories, highlighting the areas in need of improvement.

Review the following breakdown of the problems CMS found in each category outlined in the “2018 Medicare Fee-for-Service Supplemental Improper Payment Data” as part of its Comprehensive Error Rate Testing (CERT) program — and how you can avoid making the same mistakes.

Insufficient Documentation

CMS found that the vast majority of improper payments this past year — 58 percent — were due to insufficient documentation. In these situations, the medical records do not substantiate whether the service was medically necessary.

Example: The documentation includes the phrase “emergency visit for ear pain.” The record lacks a date of service, an explanation of any exam performed or history of present illness, or any other details. Therefore, the reviewer marks this claim as non-payable since it is lacking even basic documentation to demonstrate anything that the physician did.

Medical Necessity Errors

About 21 percent of improper payments last year were due to medical necessity errors. In these situations, the patient receives a service or product, but does not have a documented medical need for it.

Example: The patient from the ear pain example above is found to have a buildup of earwax. The physician bills cerumen removal (69210, Removal impacted cerumen requiring instrumentation, unilateral) and the payer reimburses the charge. However, the subsequent review shows that the physician was simply moving aside ear wax to visualize the eardrum, which is not a covered service.

Incorrect Coding

About 12 percent of the improper payments that CMS identified were due to incorrect coding. In these situations, the wrong code was reported for the service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …). The documentation demonstrates a problem-focused history and exam, and the medical decision-making is of straightforward complexity, leading the reviewers to downcode this visit to 99212.

No Documentation

Some 2.6 percent of improper payments were attributed to no documentation errors. Under these circumstances, the provider either did not document the service at all, could not find the documentation, or simply failed to submit it to reviewers.

Remember the old adage that “if it wasn’t documented, it wasn’t done” — this is how auditors will look at the situation, so you should do the same.

‘Other’ Errors

Issues that don’t fit into other categories, such as a missing signature or patient ineligibility for benefits, are classified as “other” errors, and these occurred in 6.3 percent of cases, according to the CERT report.

Example: The physician sees a patient and suspects a urinary tract infection, so he orders a urinalysis. However, he did not sign the order for the urine test, and it is therefore not payable.