Otolaryngology Coding Alert

ENT specialists were responsible for over $79 million in projected improper payments.

Otolaryngologists sometimes have to pivot between seeing patients in the office, performing surgeries, and scheduling hospital rounds — and this can mean dealing with a wide variety of code sets and rules. That could be the reason why providers in this specialty logged a 9.8 percent Part B improper payment rate in the 2021 CERT report.

Background: CMS published its “2021 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 7, 2021, 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 a 6.3 percent improper payment rate (8.5 percent for Part B) among claims submitted during the 12-month period from July 1, 2019 through June 30, 2020.

Otolaryngologists had a higher improper payment rate than the overall average, and the error rate for this specialty nearly doubled from 5.4 percent in last year’s report. Although 2021 was certainly a year that presented new challenges, from seeing more patients via telehealth to understanding new E/M rules, physicians are expected to properly document, and providers and coders are still expected to code and bill ENT specialists’ services properly.

Insufficient Documentation Among Biggest Issues for Otolaryngologists

When it came to the reasons behind otolaryngologists’ improper payments, insufficient documentation was the biggest culprit, representing 57 percent of the errors. Close behind was incorrect coding at 43 percent.

Remember that the physician’s documentation is key to supporting every code level. This may be more challenging than ever now that practices are dealing with new E/M coding guidelines that require them to select outpatient E/M codes based on either the total time spent with the patient or the medical decision making (MDM). Keep in mind, however, that E/M services for inpatient, emergency department, and other places of service still rely on the 1995 and 1997 guidelines.

“Many practices did not realize that changes to patient forms, EHR templates, and manual documentation formats needed to be reworked before the start of last year in order to best support the 2021 E/M guidelines for office and other outpatient services,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. “As a result, the support systems in place for physicians did not adequately provide what they needed to fully take advantage of the ‘Patients over Paperwork Initiative’ and best practices for documenting for the new E/M guidelines.”

Insufficient documentation doesn’t necessarily mean that your practice has lost or truncated its existing documentation — instead, it often means that the provider didn’t document enough in the first place to justify the services you billed.

Example: The physician’s documentation for an E/M service states, “Patient presented to evaluate continuing throat pain.” The record lacks a date of service, an explanation of any exam performed, or history of present illness, and may also be missing many other details. Therefore, the reviewer marks this claim as non-payable since it is lacking even the most basic information that would allow it to qualify for an E/M code (99202-99215).

When it comes to incorrect coding, reviewers note this type of error when you report the wrong code for a service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter) for an office visit with a patient. The documentation demonstrates that the otolaryngologist only spent 15 minutes with the patient and that the MDM was straightforward. Therefore, the visit is downcoded to 99212 (… straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter).

“Keep in mind that the new E/M guidelines are designed to pay the physicians for their cognitive work applied to the encounter,” Cobuzzi says. “But if the physician does not document their thought process, the diagnoses they are ruling out in addition to the final diagnosis, the plans of care being considered in addition to the final plan of care, and any mitigating factors such as social determinants of health or patient’s refusal to follow the physician’s advice, the auditor will not see what the physician’s cognitive work was during the encounter.” The 2021 E/M guidelines are designed for the physicians to show their work, so that whoever reviews documentation can see everything the physician was thinking and the physician can get credit for that when determining the E/M level.

Also, physicians tend to only indicate what they find that is abnormal, Cobuzzi adds. “So, instead of indicating all of the anatomical areas viewed when performing a diagnostic endoscopy, the physician tends only to list the problem areas. But auditors expect to see documentation of all areas viewed and confirmation that the full anatomy was examined. As such, make sure that the full anatomy that an endoscopy reviews is addressed in the documentation, listing both normal findings and abnormal findings.”

Check Which E/M Codes Featured the Most Errors

CMS breaks down which codes had the most incorrect coding errors among all Part B providers, with the following among the biggest offenders:

• Established patient office visits. The outpatient established E/M codes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …) represented $722.8 million in projected improper payments.
• Subsequent hospital visits. The codes for subsequent hospital care (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient …) represented $498.3 million in improper payments.
• Initial hospital visits. In the initial hospital visit E/M category (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient …), Medicare made $463.9 million in projected Part B improper payments.
• New patient office visits. The new patient E/M codes (99202-99205, Office or other outpatient visit for the evaluation and management of a new patient …) were responsible for $256.1 million in improper payments.
• Hospital visit – critical care. Critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …) logged $134.8 million in projected improper payments.

As most practices are aware, it’s critical to ensure that you’re reporting your E/M services accurately, since these codes represent a major slice of your practice’s income. Particularly in light of the reimbursement losses that many otolaryngologists have faced due to the COVID-19 pandemic, you want to hang on to as much of your income as you can, and correct coding is the best way to do that.

Resource: To read the full CERT document, visit https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0.