Neurosurgery Coding Alert

Insufficient documentation errors found as major mistakes for Part B providers.

As you are busy submitting multiple claims every day in your neurosurgery practice, you must be diligent on each and every claim, or errors could creep in. In fact, the top errors in neurosurgery clocked in with insufficient documentation at 27 percent and incorrect coding at 72.3 percent, according to the latest report from CMS.

Background: CMS recently released the “2019 Medicare Fee-for-Service Supplemental Improper Payment Data” report as part of its Comprehensive Error Rate Testing (CERT) program. The CERT report breaks down the biggest errors among Medicare claims and covers the causes of the improperly paid charges. Overall, the government found a 7.25 percent improper payment rate among Part A and B claims during 2019, which represented a total of $28.9 billion in improper payments.

Spot These Medical Necessity, Incorrect Coding, and Downcoding Improper Payments

You’ll find typical neurosurgery procedures on the following lists: “Top 20 Types of Services with Medical Necessity Errors,” “Top 20 Types of Services with Incorrect Coding Errors,” and “Top 20 Types of Services with Downcoding Errors.”

When looking at the “Top 20 Types of Services with Medical Necessity Errors,” found in Table F3, you will find the following projected proper payments:

• For spinal fusion, except cervical, the projected improper payments were over $67 million.
• For degenerative nervous system disorders, the projected improper payments were over $66 million.
• For cervical spine fusion, the projected improper payments were over $47 million.

You will also see “spinal fusion, except cervical” on both the “Types of Services with Incorrect Coding Errors” list found in Table F4 and the “Top 20 Types of Services with Downcoding Errors” list found in Table F5.

For incorrect coding, the projected improper payments for “spinal fusion, except cervical” was $44 million.

And, for downcoding, “spinal fusion, except cervical” came in with $34 million in projected improper payments.

“Given the component coding nature of spinal procedures (multiple codes are reported for different components, some of which require application of appropriate modifiers), it is not surprising that a majority of claims were found to have errors,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “Since there are often circumstances of bundling, it is important to keep up to date with educational programs to help you navigate the complexities of spinal surgery coding.”

Advanced Imaging Ranks on “Improper Payments by Service Type, Part B” List

CERT also recognized improper payment rates for advanced imaging procedures your neurosurgeon may perform.

For example, advanced imaging (CAT/CT/CTA) of the brain/head/neck had projected improper payments of $22 million.

Also, advanced imaging (MRI/MRA) of the brain/head/neck had projected improper payments of over $12 million.

Many Errors Due to Insufficient Documentation

Across the board, CERT found that the top errors in all specialties for Part B providers fell under “improper payments due to insufficient documentation.” Inconsistent records ranked as 28.2 percent of the errors, missing/inadequate orders came in at 7.3 percent, and missing/inadequate records came in at 30.6 percent.

CERT also identified the top root causes of insufficient documentation errors in Part B providers. They are as follows:

• Documentation to support medical necessity is missing or inadequate.
• A valid provider’s order is missing or inadequate.
• Documentation to support the services were provided or other documentation required for payment of the code is missing or inadequate.
• Valid provider’s intent to order (for certain services) is missing or inadequate.
• A signature log to support a clear identity of an illegible signature or an attestation for documentation received without a signature is missing.
• Result of the diagnostic or laboratory test is missing.

Look at These Issues With E/M Services

CERT also looked at the evaluation and management (E/M) services that had the most projected improper payments, as found in Table K1. Take a look at the top three on the list:

• 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, coming in at 79 percent.
• 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, coming in 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...)

Bottom line: CERT found “incorrect coding” as the top error among the E/M codes, resulting in the most improper payments. To avoid making incorrect coding mistakes in your practice, always make sure that you read the medical documentation carefully, understand and follow your CPT^® and ICD-10 guidelines, and learn your payers’ specific rules.

Particularly given the documentation requirements for E/M services and the additional complexity that electronic health records (EHRs) have brought, it is more important than ever to be familiar with reporting requirements and confirm that the documentation supports the level of service being claimed, Przybylski says.

Resource: To read the full CERT document, visit  https://www.cms.gov/files/document/2019-medicare-fee-service-supplemental-improper-payment-data.pdf