Oncology & Hematology Coding Alert

Insufficient documentation one of biggest errors found in latest report by CMS.

As you are busy submitting multiple claims every day in your oncology practice, you must be diligent with each and every one, or errors could creep in. In fact, hematology/oncology providers logged a 1.8 percent error rate, according to the latest report from CMS. While that doesn’t seem like a big number, it equates to $121 million dollars in improper payments.

Background: CMS recently released the “2019 Medicare Fee-for-Service Supplemental Improper Payment Data” report as part of its Comprehensive Error Rate Testing (CERT) program. The CERT report breaks down the biggest errors among Medicare claims and covers the causes of the improperly paid charges. Overall in summary, the government found a 7.3 percent improper payment rate among Part A and B claims during 2019, which represented a total of $28.91 billion in improper payments. (See page 66 in the document found at the below URL.)

Catch Oncology Services With Highest Improper Payments

You will find the improper payment rates and amounts by provider type and type of error in Table I1 and J1. Here, CMS reports:

• Oncology/hematology visits logged a 1.8 percent improper payment rate, totaling over $121 million in projected improper payments. The insufficient documentation rate is a whopping 61.6 percent, while the incorrect coding rate is 35 percent.
• Medical oncology had a 8.7 percent improper payment rate, totaling $94 million in projected improper payments. 83.7 percent due to insufficient documen­tation and 15.7 percent due to incorrect coding.
• Meanwhile, radiation oncology had a 1.0 percent improper payment rate, totaling over 13 million in projected improper payments. The insufficient documentation rate is 43.6 percent, while the incorrect coding rate is 33.8 percent.

Break this down: Take a look at some oncology-specific services from Table G1: “Improper Payment Rates by Service Types, Part B”:

• “Lab tests – Blood counts” logged in with an improper payment rate of 8.9 percent. The projected improper payment was over $23 million.
• “Oncology – radiation therapy” logged in with an improper payment of 1.4 percent. The projected improper payment was over $16 million.
• “Oncology – other” logged in with an improper payment of 1.5 percent. The projected improper payment was approximately $3.5 million.

Look at These Issues With E/M Services

CERT also looked at the E/M services that had the most projected improper payments. Table H1 “Improper Payment Rates for Office visits - established by Provider Type” ranks hematology/oncology as the least erroneous of various practices with a 3.7 percent improper payment rate; however, that still equates to over $19 million in projected improper payments.

According to Table K1 “E&M Service Types by Improper Payments”, the top three on the list are:

• 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…) With an improper payment rate of 24.1 percent, this code accounted for over $433 million in projected improper payments. Incorrect coding was the top error found with 99223, coming in at 79.9 percent.
• 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 …) With an improper payment rate of 5 percent, this code accounted for over $423 million in projected improper payments. Incorrect coding was the top error, coming in at 66.8 percent.
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity…) With an improper payment rate of 6.9 percent, this code accounted for over $366 in projected improper payments. Incorrect coding ranked as the top error at 81.4 percent.

Bottom line: CERT found “incorrect coding” as the top error among the E/M codes, resulting in the most improper payments. To avoid incorrect coding mistakes in your practice, always make sure you read the medical documentation carefully, understand and follow your CPT^® and ICD-10-CM guidelines, and learn your payers’ specific rules.

Particularly given the documentation requirements for E/M services and the additional complexity that electronic health records (EHRs) have brought, it is more important than ever to be familiar with reporting requirements and confirm that the documentation supports the level of service being claimed, says Gregory Przybylski, MD at the JFK Medical Center in Edison, New Jersey.

Resource: To read the full CERT document, visit https://www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf