Ob-Gyn Coding Alert


Medical Necessity Errors Result in Over $22 Million Projected Improper Payments for Ob-Gyn

Find out what E/M codes cause the most mistakes.

You know that medical necessity, correct coding, and sufficient documentation are just some of the details you must pay attention to as you submit claims in your ob-gyn office. However, no matter how careful you are, errors can still crop up. Unfortunately, ob-gyns logged an 8.1 percent improper payment rate, resulting in over $22 million of projected improper payments.

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.

Be Aware of Insufficient Documentation

Some of the top mistakes ob-gyn practices made that resulted in improper payments included no documentation reported at a 13.6 percent error rate, insufficient documentation at a 42 percent error rate, and incorrect coding at a 44.4 percent error rate.

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

  • The documentation to support the medical necessity was missing or inadequate.
  • The documentation to support that the services were provided or other documentation required for payment of the code was missing or inadequate.
  • The provider’s intent to order or the order was missing.

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 during the dates of this study. Remember: As of Jan. 1, 2021, new patient code 99201 no longer exists.
  • 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