Pulmonology Coding Alert

Plus: Pulmonologists logged high error rates when billing subsequent hospital care.

Because pulmonologists are often the primary caregivers for critically ill patients, these specialists spend a lot of time in the hospital setting. This can mean diagnosing patients, admitting them, billing for critical care, and reporting subsequent hospital care codes — plus knowing all of the outpatient coding rules as well. Sometimes this can lead to confusion among the codes, which appears to have been the case in the 2019 CERT report.

Background: CMS issued its “2019 Medicare Fee-for-Service Supplemental Improper Payment Data” on December 18 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 an 8.6 percent improper payment rate among Part B claims submitted during the 12-month period from July 1, 2017 through June 30, 2018.

Pulmonology Visits Logged Millions in Part B Errors

On the list of the specialties with the most Part B improper payments, CMS ranks pulmonologists high, logging a 13 percent overall improper payment rate, totaling over $169 million in improper payments.

Drilling down to the data, pulmonologists also ranked high on the list of providers that had the most errors when it came to subsequent hospital visits. With a 12.8 percent improper payment rate in this category, physicians treating pulmonary disease were responsible for nearly $44 million in improper payments just for their subsequent hospital care services. Only three other specialties (internal medicine, nephrology, and family practice) logged higher improper payment amounts for subsequent hospital care.

Insufficient Documentation Among Biggest Problems for Pulmonologists

When it came to the reasons behind pulmonologists’ improper payments, insufficient documentation was the biggest culprit, representing almost 54 percent of the errors. Close behind was incorrect coding at almost 45 percent.

It’s essential to remember that the physician’s documentation is key to supporting every code level, says Terri Tamez, CPC, CEO of Phoenix Coding and Consulting Service. For E/M claims, this means documenting an appropriate level of history, exam, and medical decision making (MDM). It’s that last element that trips up quite a few coders due to its complexity.

To determine the level of MDM, you should assign points to each of the three MDM components that your pulmonologist performs. The number of points in each category determines the final MDM level. The elements are diagnoses/management options, complexity of data reviewed/ordered, and the risk of complications/morbidity/mortality.

You must have two out of the three MDM components score at a particular level in order to assign that level of MDM. For example, if the number of diagnoses is low, but the amount and complexity of data and level of risk are both moderate, your MDM score is moderate. An alternative method to determine the correct level of MDM is to eliminate the highest and lowest scores, and the remaining score is the level for the particular MDM in question.

“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 medical decision making,” 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.”

In other cases, the physician may document the MDM but the coder is unable to discern the medical necessity of the decisions that the physician made. For instance, says Marie Franklin, MBA, CPC, national director of coding, education, and audit with AdvantEdge Healthcare Solutions, some physicians will document “Old records reviewed” and expect to count that toward the complexity of data reviewed. “We need to know what they mean when they document this,” Franklin says. “How is that relevant to today’s visit? Elaborate a little more on that if you want credit for it. As the coder, I need to understand how this affected decision making.”

Initial Hospital Care Logs High Error Rate

Topping the overall list of E/M services paid improperly was 99223 (Initial hospital care, per day, for the evaluation and management of a patient…), which is the highest level of initial hospital care. Far exceeding the national average for improperly paid claims, this code saw an error rate of 24.1 percent. This led to about $433 million in improper payments over the past year.

Chief among the issues with 99223 was incorrect coding, which represented about 80 percent of the improper charges for the service. Coming in a close second was insufficient documentation, which was responsible for about 17.5 percent of the improper payments.

When it came to outpatient codes, 99214 (Office or other outpatient visit for the evaluation and management of an established patient…) hit the top of the list, generating about $423 million in improper charges, driven by incorrect coding in 67 percent of cases and insufficient documentation in 28 percent of them.

Resource: To read the full CERT document, visit cms.hhs.gov/cert and click “CERT Reports” on the left side of the page. From there, you can download the 2019 report.