General Surgery Coding Alert

E/M leads coding trouble spots.

Even if your surgeons strive for excellent documentation and your coders check to ensure the record demonstrates medical necessity and accurately matches coding on claims, you have room for improvement. That’s according to the latest Comprehensive Error Rate Testing (CERT) report from CMS, which lists a 5.8 percent improper payment rate among general surgery providers.

Read on for a snapshot of how general surgery practices fared in the latest CERT report and use the news to focus on improving your documentation and coding practices in 2020.

See How CERT Data Impacts Your Practice

CMS uses the information garnered from the CERT program in three different ways that you need to know.

First, CMS uses providers’ data to “protect the Medicare Trust Fund by identifying errors and assessing error rates, at both the national and regional levels,” according to Part B Medicare Administrative Contractor (MAC) CGS Medicare in its CERT guidance.

Second, the government tracks error trends among certain provider types, codes, and services through the CERT program. These findings help CMS pinpoint problem areas that are perennially an issue and ratchet up the improper payment rate, costing taxpayers billions. The agency then uses this valuable information to rein in outliers, rectify issues, and promote program integrity, CGS suggests.

Lastly, CMS uses the information garnered from the report to measure how MACs are doing. The CERT data helps to determine regional programming and education, including tools like the Targeted Probe & Educate (TPE) program and Comparative Billing Reports (CBRs) in a jurisdiction.

“CERT is an excellent program that provides extremely helpful information for physicians,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department. “It’s really important for physicians to keep an eye out because there is a lot of overcharging and unnecessary billing for services that lack the proper medical necessity.”

Focus on General Surgery Coding Breakdowns

You will find the improper payment rates and amounts by provider type and type of error in Table I1 and J1. Here, CMS reports that general surgeons logged a 5.8 percent improper payment rate.

Of those payment discrepancies, 29.4 percent were attributable to insufficient documentation for general surgery procedures, with a whopping 64.4 percent due to coding errors.

Table G1 and H2 of the CERT report shows several general surgery services that demonstrate the following improper payment rates:

• Endoscopy 7.1 percent
• Major procedures 8.4 percent
• Minor procedures, skin 7.9 percent
• Hospital visits 11.1 percent

Look at These Issues With E/M Services

The CERT report showed the leading types of service with incorrect coding errors in Table F4, and E/M services took the top four spots. Established office visits accounted for 2.5 percent of overall improper payments, while initial hospital visits accounted for 1.6 percent, subsequent hospital visits accounted for 1.3 percent, and new office visits accounted for 1.2 percent of overall payment errors to Medicare.

Specifically, the following three E/M codes showed the most improper payments, as found in table K1:

• 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…): With an improper payment rate of 24 percent, this code accounted for over $433 million in projected improper payments. Incorrect coding was the top error found with 99223, occurring in 79 percent of improperly paid claims.
• 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 …): With an improper payment rate of 5 percent, this code accounted for over $423 million in projected improper payments. Incorrect coding was the top error at 66.8 percent.
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity…): With an improper payment rate of 6.9 percent, this code accounted for over $366 in projected improper payments, with incorrect coding ranking as the top error at 81.4 percent.

Problem: If your surgeons are constantly reporting the same E/M code — such as 99214 — for every office visit, then you’re inviting errors that can lead to audits.

Solution: Look through the patient’s documentation and properly account for all the components of the E/M service, and then arrive at the proper code for the encounter.

“It would be a very rare situation in which the history, exam, and medical decision making of every patient seen by a physician led to the same E/M code,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “A review of the documentation should generally reveal some variation in the level of service provided to different patients.”

Bottom line: “Every dollar spent inappropriately is one that should have been used to benefit patients,” explains CMS administrator Seema Verma in a release. The agency “is pulling every lever at its disposal to safeguard precious resources and direct them to those who truly need them.”

Resources: Review the CERT report at www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf. Learn more about Medicare’s medical record documentation requirements at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf.