CMS Identifies E/M Codes With High Error Rates
Coding initial hospital care became more challenging after Medicare stopped paying for inpatient consult codes several years ago — but that can’t be the only factor driving the startling error rates for evaluation and management (E/M) codes 99223 and 99214.
In the report “2019 Medicare Fee-for-Service Supplemental Improper Payment Data,” the Centers for Medicare & Medicaid Services (CMS) outlines the most significant 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 from July 1, 2017, through June 30, 2018.
Initial Hospital Care Code 99223 Tops the Charts
Topping the list of improperly paid E/M claims was CPT® 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. This code reports the highest level of initial hospital care. Far exceeding the national average for improperly paid claims, 99223 saw an error rate of 24.1 percent, amounting to about $433 million in improper payments in just one year.
According to the report:
- 80 percent of the improper payments were due to incorrect coding, and
- 5 percent of the improper payments were due to insufficient documentation.
Tips for Coding 99223
Based on these high improper payment rates, now is a good time to refresh your knowledge of the 99223. Here are some best practices to ensure your claims don’t add to the statistical error rate next year:
- One physician should bill for inpatient encounter: Do not assume you can bill for initial inpatient care (99221-99223) just because the doctor performed a face-to-face visit with the patient in the hospital on the day of admission. If an inpatient claim has already been submitted by another provider, select a subsequent hospital care code (99231-99233).
- Admitting/attending physician should append modifier AI: Only the admitting/attending physician can bill an initial inpatient hospital care E/M code. That healthcare professional should append modifier AI Physician of record to the initial inpatient code when billing Medicare. Other payers have adopted this rule as well.
- Know the status: Make sure the patient your physician visits in the hospital has been admitted as an inpatient. Not all facility settings qualify as “inpatient” status. The emergency department, for instance, is an outpatient setting, and the inpatient codes don’t apply there.
- Meet three of three: Initial hospital care visits must meet all three code requirements (history, exam, and medical decision making). Subsequent hospital visit codes (99231-99233) only require two of the three elements.
Outpatient E/M Code 99214 also at Risk
CPT® 99214 Office or other outpatient visit for 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 hit the top of the error list for outpatient E/M codes. This code amounted to about $423 million in improper charges.
According to the report:
- 67 percent of the improper payments were due to incorrect coding, and
- 28 percent of the improper payments were due to insufficient documentation.
CMS also examined which specialties generated the most Part B errors. Internal medicine ranked the highest, racking up over $1 billion in projected improper payments. Not far behind were clinical laboratories and family practices.
More on Claims Payment Errors and Causes
As part of its Comprehensive Error Rate Testing (CERT) program, CMS reports the most significant errors among Medicare claims annually. To review the rest of the errors CMS found among 2019 Medicare claims, visit the CERT website and download the 2019 report.