Pulmonology Coding Alert

CMS identified a total of $28.9 billion in total improper payments among providers sampled in the 2019 CERT report, and broke down those charges into a variety of categories. Check out the following breakdown of how many problems the agency found in each category, and how you can avoid making the same mistakes.

Insufficient Documentation

CMS found that the vast majority of improper payments — 59.5 percent — were due to insufficient documentation. In these situations, the medical records do not substantiate whether the service was medically necessary.

Example: The documentation includes the phrase “Visit to evaluate blood in sputum.” 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 basic documentation to demonstrate anything that the physician did.

Medical Necessity Errors

About 18.7 percent of improper payments last year were due to medical necessity errors. In these situations, the patient receives a service orproduct, but does not have a medical need for it.

Example: The patient from the blood in sputum example above is seen by the physician, who orders a four-view chest x-ray (71048). Since bloody sputum alone typically does not provide the medical necessity for four views, the insurer is likely to deny this claim for a lack of medical necessity.

Incorrect Coding

About 14 percent of the improper payments that CMS identified were due to incorrect coding. In these situations, the wrong code was reported for the service, either via upcoding, downcoding, or miscoding.

For example: A provider reports 99214 (Office or other outpatient visitfor 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…) for an office visit with a patient. The documentation demonstrates a problem-focused history and exam, and the medical decision-making is of straightforward complexity, leading the reviewers to downcode this visit to 99212 (Office or other outpatient visit for the evaluation and management of an established patient…).

No Documentation

Some 2.1 percent of improper payments were attributed to “no documentation” errors. Under these circumstances, the provider either did not document the service at all, could not find the documentation, or simply failed to submit it to reviewers.

Remember the old adage that “if it wasn’t documented, it wasn’t done” — this is how auditors will look at the situation, so you should do the same.

“Other” Errors

Issues that don’t fit into other categories, such as a missing signature or patient ineligibility for benefits, are classified as “other” errors, and these occurred in 6 percent of cases, according to the CERT report.