Pulmonology Coding Alert

Medicare reviewers revealed details about the latest Part B E/M improper payment rates.

Pulmonologists often have to straddle the line between working in the outpatient setting and working with critically ill inpatients. This means juggling a variety of code sets, which can create confusion when it comes to selecting the right codes. That could be the reason why providers in this specialty logged an 8.6 percent Part B improper payment rate in the 2020 CERT report.

Background: CMS issued its “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.

Although pulmonologists had a higher improper payment rate than the overall average, the rate for this specialty did come down from 13 percent in last year’s report. The 8.6 percent error rate that pulmonology practices logged in the most recent document represents $121.7 million in projected improper payments, the agency noted.

Incorrect Coding Among Biggest Issues for Pulmonologists

When it came to the reasons behind pulmonologists’ improper payments, incorrect coding was the biggest culprit, representing almost 72 percent of the errors. Close behind was insufficient documentation at almost 25 percent.

Remembering that the physician’s documentation is key to supporting every code level is essential, says Terri Tamez, CPC, CEO of Phoenix Coding and Consulting Service. 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).

“We often have to remind the physicians to document their thought process within the encounter of their electronic medical record,” Tamez says. “The ‘risk’ of presenting problem or potential illness/injury does factor into the MDM,” she adds.

In addition, Tamez notes, you must document the differential diagnoses that the physician considers which require additional workup or treatment. “This helps the coders know if this patient has a potential high-risk problem,” she adds. “Remember, the chart reviewer cannot assume why you ordered certain tests. Coders cannot interpret, infer, or imply why any treatment or tests are ordered.”

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 $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, since these codes represent a major slice of your practice’s income. 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.