Neurosurgery Coding Alert

Here are the claims that could be costing your practice well-deserved reimbursement.

Your neurosurgery practice is probably active and bustling every day, but it’s possible that with all that activity, correct coding could be falling through the cracks. Neurosurgery practices logged over $253 million in improper payments, per the latest CERT report. Learning which common medical coding errors CERT has identified will go a long way to helping you avoid these same mistakes in your own neurosurgery practice.

The backstory:  CMS issued its “2018 Medicare Fee-for-Service Supplemental Improper Payment Data” on November 30 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 an 8.1 percent improper payment rate among Part B claims during 2018.

Dial Into Neurosurgery Services With Highest Improper Payments

CERT has identified some of the top neurosurgery mistakes. Being aware that the following procedures and diagnoses are hot spots can help you avoid making these same mistakes in your own practice:

• Degenerative nervous system disorders logged over $67 million of projected improper payments. There was a 7.8 percent improper payment rate.
• Spinal fusion, except cervical logged in over $55 million for projected improper payments.
• Intracranial hemorrhage or cerebral infarction came in at over $38 million in projected improper payments.
• Peripheral cranial nerve and other nervous system procedures came in with over $15 million for projected improper payments. There was a 9 percent improper payment rate.
• Extracranial procedures logged in at over $12 million for projected improper payments.
• Craniotomy and endovascular intracranial procedures saw over $8 million in projected improper payments.
• Back and neck procedures, except spinal fusion logged in over $58 million for projected improper payment rate. There was a 22 percent improper payment rate.

Make Medical Documentation a Priority in Your Practice

Unfortunately, medical documentation mistakes are one of the top causes of CERT errors, according to the report. Root causes of insufficient documentation errors in Part B include the following:

• Documentation to support medical necessity was not submitted.
• A valid provider’s order or element of an order was not submitted.
• A valid provider’s intent to order (for certain services) was not submitted.
• Documentation to support the services were provided or were provided as billed was not submitted.
• Documentation of result of the diagnostic or laboratory test was not submitted.
• A signature log of medical personnel to support a clear identity of an illegible signature was not submitted or the provider’s written attestation of the unsigned or illegible signature was not submitted.

You should always pay close attention to the medical documentation, so you can avoid making these errors in your own practice, says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee.

Observe These E/M Codes Under Scrutiny

Though incorrect coding is only one category that CMS factors into its overall error rate, the CERT report spotlights the major impact E/M services have on improper payments. The overall impact of all E/M service types on the error rate was 11.9 percent with more than $3.8 billion being improperly paid out to providers for the prominent CPT^® codes, according to Table K1 of the CERT report. Here’s a breakdown of the top three E/M codes causing the biggest problems in the CERT data from Table K1:

1. 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity…) ranks first on the CERT report’s E/M worries. With an improper payment rate of 27.2 percent, this confusing CPT^® code accounted for 1.4 percent of the overall error rate and more than $456 million in improper payments.

2. 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 …) took the second spot with an error rate of 4.8 percent and an overall impact of 1.2 percent. This popular E/M office visit code was improperly paid to the tune of $389 million.

 3. 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …), which was the number one E/M issue in 2017, was bumped down to third for 2018, and contributed to 1.1 percent of the overall error rate with an individual code error rate of 19.1 percent. Issues with 99233 contributed to $365 million in improper payments.

Heads up: You should also note that 99223, 99214, and 99233, in addition to others in their code groups, are already in various stages of active prepayment review for the MACs that publish their Targeted Probe and Educate (TPE) topics. And according to CMS guidance, providers should expect more scrutiny of these codes and claims down the line.

The agency plans to increase its “provider outreach and education” with an uptick of “Targeted Probe and Educate initiative[s] to reach individual providers with educational interventions and we’re also enhancing these efforts to allow for flexible and consistent user training,” CMS Administrator Seema Verma said on the improper payment issues.

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/2018MedicareFFSSuplementalImproperPaymentData.pdf.