Podiatry Coding & Billing Alert

Insufficient documentation was the top mistake for podiatrists.

Whether you are a new or seasoned coder, you know how important supporting medical documentation, medical necessity, and proper coding are when it comes to submitting clean claims in your podiatry practice. Unfortunately, due to mistakes just like these, podiatrists logged a 12.9 percent improper pay rate, resulting in over $182 million of projected improper payments, per CMS’ most recent CERT report.

Background: CMS issued the “2020 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 21 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 (8.1 percent for Part B) among claims submitted during the 12-month period from July 1, 2018 through June 30, 2019.

Check Out These DMPEOS Mistakes

Per the “I2: Improper Payment Rates and Amounts by Provider Type: DMPEOS” Table, podiatry had an improper pay rate of over 68 percent, resulting in over $65 million of projected improper payments. Insufficient documentation was the top mistake for podiatrists contributing to this improper pay rate, coming in at 80 percent.

In Table D2, “Top 20 Service Types With Highest Improper Payment Payments: DMPEOS,” lower limb orthoses had an improper payment rate of over 65 percent, resulting in over $501 million projected improper payments.

Additionally, diabetic shoes had an over 68 percent improper payment rate, resulting in $82 million of projected improper payments.

Also, in Table E2, “Top 20 Service Type Improper Payment Rates: DMPEOS,” orthopedic footwear came in at an over 84 percent improper pay rate.

Be Aware of Insufficient Documentation

Some of the top mistakes podiatrists made that resulted in improper payments included no documentation coming in at over 12 percent, insufficient documentation at over 64 percent, medical necessity at 1.9 percent, and incorrect coding at over 20 percent.

CMS identified some of the top causes of insufficient documentation for Part B providers. These include the following:

• The documentation to support the medical necessity was missing or inadequate.
• The documentation to support the services were provided or other documentation required for payment of the code was missing or inadequate.
• The provider’s intent to order or the order was missing.

See Which E/M Codes Featured the Most Errors

CMS breaks down which evaluation and management (E/M) 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 $400.9 million in projected 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 $359.5 million in projected Part B 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 $261.6 million in improper payments.
• New patient office visits. Coming in fourth on the list, 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 $260.6 million in improper payments.
• Hospital visit – critical care. The fifth code series with incorrect coding error involved critical care visits (99291- +99292, Critical care, evaluation and management of the critically ill or critically injured patient …), logging $146.1 million in projected improper payments.

As most practices are aware, it’s critical to ensure that you’re reporting your E/M services accurately. Particularly in light of the reimbursement losses that many physicians are facing due to the 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 www.cms.gov/restricted-access-vbdlvcertreportsdl/2020-medicare-fee-service-supplemental-improper-payment-data.