Oncology & Hematology Coding Alert

Surprise: Medicare found some oncologists undercoding

Errors in billing, coding and documentation led to more than $100 million in improper payments to oncologists between Oct. 1, 2005, and Sept. 30, 2006 -- and you-d better believe that Medicare will want to shrink that number significantly in the future.

The latest results of Medicare's Comprehensive Error Rate Testing (CERT) program, released in May, project these improper payments based on their review of a sample of submitted claims.

CERT found the following error rates and improper payments for oncologists:

• Hematology/Oncology: 2.1 percent error rate; $80,369,362 improper payments
• Medical Oncology: 1.6 percent error rate; $20,041,330 improper payments
• Radiation Oncology: 0.7 percent error rate; $8,188,955 improper payments.

Although the majority of the errors for all specialties were due to medical necessity or incorrect coding, many were also caused by faulty documentation -- the providers produced insufficient documentation to back up their claim, or, in some cases, no documentation at all.

-Improper Payments- Go Both Ways

CERT's findings are not all one-sided. The review found several instances of underpayment, in which Medicare should have paid the practice more.

The main culprit? Coding errors, says CERT -- undercoding led to practices in all specialties receiving about $236 million less than they deserved during the survey period.

Avoid this practice's mistake: One medical oncology practice billed Medicare for 5 mg of dexamethasone sodium phosphate (J1100), but the documentation revealed that the practice actually dosed 20 mg. This means the practice shorted itself for 15 mg worth of reimbursement.

However: A far more common error was upcoding -- reporting a higher-level code than the documentation supports.

For example, one hematology/oncology office submitted a claim for 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient), an E/M code that requires any two of these elements:

• expanded problem-focused interval history
• expanded problem-focused examination
• medical decision-making of moderate complexity.

After reviewing the documentation, CERT judged that the physician only performed a problem-focused history and low-complexity medical decision-making. There was no record of any exam.

CERT found that this service should have actually been reported with 99231 (Subsequent hospital care, per day ...).

Lesson learned: Be sure the documentation in the patient's record backs up your claim because you never know when CMS might want to dig into your archives.