ED Coding and Reimbursement Alert

Check out the highlights from the government's latest error report to find out what auditors discovered.

To err is human - but to find those errors is an art form. That is, according to CMS's auditors, who pored over claims from last year and compiled them into the government's new Comprehensive Error Rate Testing (CERT) results, which were released on July 27.

According to the "Medicare Fee-for-Service 2016 Improper Payments Report," the government found an 11.7 percent Part B error rate, which included $10.4 billion in overpayments to providers and $0.5 billion in underpayments. Although that second number may sound low, the reality is that it means CMS underpaid doctors by $500 million - and that means those practices shorted themselves significantly.

State level errors: According to the report, the US states with the highest error rates were California, Texas, Florida, Pennsylvania, and Illinois.

Overall, the report indicates, the vast majority of improper payments were due to insufficient documentation errors. "In other words, the CERT contractor reviewers could not conclude that the billed services were actually provided, were provided at the level billed, and/or were medically necessary," the report noted.

Check out the following errors that the report highlighted to find out how your ED can steer clear of similar problems and ensure that you're collecting the right amounts every time.

This ED Couldn't Demonstrate Cause for Admitting Patient

CMS's report cuts straight to the heart of medical necessity errors with the following example, which involved a decision to admit a patient from the ED to the hospital when the documentation didn't support the admission.

"A beneficiary with a past medical history of diverticulitis, chronic obstructive pulmonary disease, and congestive heart failure presented to the hospital ED with left lower quadrant abdominal pain," CMS states in the report. "The beneficiary did not have a fever and was not in any acute distress as noted in the ED notes. Laboratory results were normal and did not indicate signs of significant infection. The computerized tomography (CT) scan report showed mild diverticulitis. The beneficiary was tolerating an oral diet. The medical record documentation did not support the need for inpatient services. Therefore, the CERT program scored this claim as an improper payment due to a medical necessity error."

It's possible that the patient in the above scenario may have a valid reason for admission - for instance, if there were other complicating factors such as an extreme of age, prior history of severe complications, or other issues, but as described, outpatient treatment with close follow-up would be most common in the above scenario, says Michael Granovsky, MD, FACEP, CPC,  president of LogixHealth, a national ED coding and billing company in Bedford, Massachusetts.

Could You Be Making Lab Test Coding Errors?

CMS also aimed its ire at practitioners who inappropriately report lab tests, which logged a 35.5 percent error rate among 2016 claims, costing the government a startling $1.3 billion last year. The CERT reviewers noted the following example in the report:

"A laboratory submitted a claim for a urine drug screen, qualitative; multiple drug classes by high complexity test method. The submitted documentation included the laboratory report and a physician's office note for the billed date of service indicating a follow-up visit for chronic neck pain. The submitted documentation was missing the physician's order and the submitted clinical documentation did not support the intent to order the billed lab tests. There was no response to an additional request for documentation. The CERT program scored this claim as an improper payment due to insufficient documentation."

In an ED with a well-used electronic medical record, not having an order for a lab test would be rare, Granovsky says. However, in a paper world it could occur, or a verbal order could be given and then not documented.

Take Note of These Documentation Tips

Consider the following seven criteria for quality clinical documentation, and evaluate how your documentation stacks up in each area so you can provide help in making any changes needed to better support coding choice. If you find that your practitioners are falling short in any of these seven critical areas, consider gathering your staff for a quick documentation primer to remind the clinicians how to document appropriately so they can justify the services they report.

1. Legibility: Documentation should be readable and easily deciphered. A lot of handwritten documentation isn't legible or decipherable. Rushed or careless documentation may cause other problems. Legibility includes being able to read the name and title of the clinician completing the documentation.

This is an especially important aspect of good documentation. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient's condition.
• Jeopardized reimbursement.
• Denied payment.
• Loss of legal appeals.
• Serious patient injury.

Although the use of electronic health records has vastly improved documentation legibility, many practices are still manually writing some notes, orders, and prescriptions by hand, so this is an area that should always be reviewed for clarity.

2. Reliability: Is the documentation trustworthy? Based on the diagnoses, is the documentation reliable? Does it support the rationale for the diagnoses and for medical necessity?

The reliability is not just related to the assessment, but with every single visit note. Most denials and downcoding instances occur when visit notes don't support the codes you report.

3. Precision: Clinical documentation must be accurate, exact, and strictly defined. Increased detail generally means greater accuracy in documentation. The degree of specificity in documentation that was made necessary with ICD-10 has been known to challenge even the most experienced clinicians. The same can be said for selecting E/M levels - without extremely thorough notes, E/M claims are often found to be upcoded because the doctor didn't record enough information to support higher codes.

4. Completeness: Good documentation fully addresses all concerns in the record, and includes appropriate validation.

5. Consistency: Documentation shouldn't be contradictory. Are there conflicting statements in the record? Are there conflicting opinions between providers that have not been clarified? Make sure any inconsistencies are addressed.

This is where smooth coordination of services comes into play. Many times, a contradiction occurs when there is a lack of communication between the disciplines, so everyone should be on the same page.

6. Clarity: Documentation should be unambiguous. Vague documentation that does not totally describe a patient's condition won't support the services your practice provides.

7. Timeliness: Documentation must be up to date to help ensure optimal patient treatment. Any delay in documenting can cause the clinician to forget important details that are critical to code selection.

Resource: To read the CERT report in its entirety, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/MedicareFeeforService2016ImproperPay­mentsReport.pdf.