Medicare Compliance & Reimbursement

CERT highlights providers' difficulties with compliant documentation.

If you bill a substantial part of your pay to Medicare, make sure your codes are in line. The agency found billions of dollars paid in error over the last year, and you could be forced to send your MAC a refund if you're one of the offenders. Read on for tips on how to avoid the most common errors that CMS uncovered during its latest audit.

Watch Your Documentation, Findings Suggest

CMS's new Comprehensive Error Rate Testing (CERT) results, which were released on Jan. 8, show that practices made fewer errors in 2017 (with a national average error rate of 9.5 percent) than in the previous year (2016's error rate was 11.0 percent). This was the third year in a row with a decline in the overall improper payment rate though a whopping $36.2 billion in improper payments were still made in 2017 despite the decrease, the CERT data noted. The biggest offenders in CMS's eyes were chiropractors, independent labs, pain management specialists, physical medicine and rehabilitation providers, and psychiatrists, all logging error rates above 20 percent.

Reminder: "If the medical record does not support the service(s) billed, CMS can certainly recoup the funds paid to the provider," explains attorney John E. Morrone, a partner at Frier Levitt Attorneys at Law in New York.

What's new: This year's CERT supplemental data includes a handy breakdown of what it defines as "insufficient data," which accounted for approximately 64 percent of the improper payment rate and $23.2 billion improperly paid out to Medicare providers andsuppliers.

"In order to provide a more thorough understanding of insufficient documentation errors, CMS examined the root causes of these errors and developed a universal error for the insufficient documentation error," explainsthe agency in the CERT report. "The root cause of the insufficient documentation error must meetthe universal error definition to be included in thatclassification."

There are five "universal error" categories. According to the CERT data, 29.9 percent of the claims examined had more than one universal error. Here is this year's list with the description and the percentages for 2017:

Avoid These Common Mistakes

You can read the 85-page CERT report on the CMS website, but we've compiled the most common incorrectly-billed services that Medicare providers perform, along with tips on how to fix these issues going forward.

Inpatient Hospital Visits: CMS found a startling 19.4 percent error rate among inpatient hospital visit codes, which most frequently stemmed from incorrect coding. In fact, the report notes, initial hospital care claims are upcoded 19.2 percent of the time.

Tip: Many coders believe they can bill for initial inpatient care (99221-99223) just because the doctor performed a face-to-face visit with the patient in the hospital on the day he was admitted. But if he has already been admitted by another provider (his attending physician), you should instead select a subsequent hospital care code (99231-99233).

Major Joint Replacements: Arthroplasty for major joints was the source of more than $301 million in improperly paid claims due to insufficient documentation, the CERT report noted.

Tip: This issue has been on the minds of CMS for a while now. When the agency issued a related MLN Matters article in 2012 and updated it again in 2015, CMS made clear that cursory rationales for surgery wouldn't pass muster. Bolding for emphasis words including "detailed" and "progress notes," CMS stressed that physicians should steer clear of notes "consisting of only conclusive statements."

Open to denial, for example, might be a justification that said simply, "Mrs. Marks is a female, age 68, with chronic right knee pain. She states she is unable to walk without pain, and pain meds do not work. Therefore, she needs a total right knee replacement." When it comes to documenting medical necessity in the physician record, evidence of failed prior conservative treatments is a must. A simplistic statement such as "bone on bone" definitely won't fly. Rather, tell each patient's clinical story in detail, including relevant clinical diagnoses and observations ("end-stage osteoarthritis of the right knee"), and progress over time ("worsened over the past ten years, NSAIDs began to cause gastric distress in December 2014, no functional improvement with physical therapy").

See the MLN Matters article at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1236.pdf.

E/M Visits Continue to be a Problem

CMS also honed in on several "problem codes" that the agency identified, including subsequent hospital care code 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...), which has a 13.3 percent error rate, and emergency department (ER) visit code 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components ...), which has an error rate of 12.4 percent.

Tip: Improperly coding the higher level ER code 99285 has been an issue and was recently covered by MAC Palmetto GBA in a recent Comparative Billing Report (CBR). (Medicare Compliance and Reimbursement, Vol. 44, No. 1.)

Consider this scenario and using a lower-level code: If during the office visit, you realize that the patient should go to the ER and you will see the patient later that day in the ER, then you should combine the work of the twoservices and report just one code - 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...).

However, if the services were truly unrelated encounters, you can report 99214 and then the appropriate ER E/M code, such as 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity...). You will need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99214. Both services need to be medically necessary/relevant and thoroughly documented. Being unrelated, they should have different primary diagnosis codes listed on the claim form.

Endnote: Going forward, you should be sure to double-check your documentation for these services and diagnoses, and if any glaring errors stand out, set up an educational session at your practice where everyone can catch up on their coding skills.

Resource: For a closer look at the most recent CERT data, visit www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2017-Medicare-FFS-Improper-Payment.pdf.