Cardiology Coding Alert

Insufficient documentation and incorrect coding top errors.

You know how important complete supporting medical documentation, medical necessity, and proper coding are when it comes to submitting clean claims in your cardiology practice. Unfortunately, due to mistakes just like these, cardiologists logged a 5.2 percent improper pay rate, resulting in over $265 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.

Top Errors Include Insufficient Documentation, Incorrect Coding

The main culprits contributing to cardiology’s $265 million of projected improper payments were insufficient documentation coming in at 51 percent and incorrect coding coming in at 35 percent.

Heart failure and shock was one of the areas where incorrect coding resulted in over $42 million of projected improper payments. Additionally, coronary bypass without cardiac catheterization landed on the list of the top 20 types of services with incorrect coding errors with projected improper payments of over $22 million.

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

• Missing or inadequate orders
• Missing or inadequate records
• Missing or inadequate plan of care
• Certification or recertification requirements not met
• Documentation to support medical necessity was missing or inadequate

Observe These Medical Necessity Errors

Heart failure and shock landed on the list of the top 20 types of services with medical necessity errors with over $70 million of project improper payments.

Chest pain was also on this list with over $79 million projected improper payments and an improper pay rate of 26.9 percent.

“Other vascular procedures” also earned a spot on the list with over $42 million in projected improper payments and a 2.4 percent improper pay rate.

Check out Improper Payments for Cardiology Services

The CERT report included a list of improper payments by service type for Part B providers, and several cardiology procedures ended up on this list.

Echography/ultrasonography of the heart came in with a 7 percent improper pay rate and over $61 million in projected improper payments.

EKG monitoring came in with a 6.4 percent improper payment rate and over $21 million in projected improper payments.

Electrocardiograms came in with a 9 percent improper payment rate and over $30 million of projected improper payments.

Finally, Cardio stress tests came in with a 6.7 percent improper payment rate and over $7 million of projected improper payments.

Interventional Cardiologists Log $69 Million in Improper Payments

Interventional cardiologists earned their own spot in the CERT report. In fact, interventional cardiologists had projected improper payments of $69 million.

Incorrect coding contributed to this overpayment at over 56 percent. Additionally, insufficient documentation contributed at 43 percent.

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 (99201-99205, 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.