Part B Insider (Multispecialty) Coding Alert

Published on Mon Apr 28, 2008 PDF

With more than $100 million overpaid for 99232, physicians poorly documented subsequent hospital care

If your favorite code is 99211, watch out. A new CMS report re-veals that more than 15 percent of claims submitted to Part B for this code last year were missing critical documentation, causing Medicare to request more than $20 million back from providers.

The CERT report found 99211 (Outpatient E/M that may not require a physician) billed inappropriately across the board, both in the -insufficient documentation- and -no documentation- categories.

-Practices may be surprised by this high error rate because many people think it doesn't take comprehensive documentation to report 99211,- says Heather Corcoran with CGH Billing. -But that's probably the exact reason it's billed in error so often--practitioners assume because it's a low-level code, they don't have to document very much information, which is wrong. Thorough documentation is necessary no matter how much money you-ll collect for a particular code.-

99232 Also on the List

Carriers requested more than $100 million back from practices last year due to insufficient documentation for subsequent hospital care code 99232, which had a 4.1 percent error rate.

Possibility: Physicians who are unsure of which hospital code to report may simply rely on 99232.

-Hospital visits are totally up to the physician or provider to document and report, so whether or not they understand what is required for each level of service is probably not known,- says Denise Paige, CPC, of Torrance Orthopaedic and Sports Medicine Group.

-It's a type of coding issue that, documentation-wise, should be re-viewed with the physician to help them understand what is required.-

Practices Undercoded as Well

Not all of the coding errors revealed in the CERT report were related to upcoding. In fact, the document reveals that Medicare should have paid out an additional $300 million, but practices undercoded claims and didn't collect their due.

The most frequently undercoded claim was 99307 (Subsequent nursing facility care), which had a 17.6 percent error rate. Not far behind was emergency department visit code 99282, followed by 99211.

To read the full CERT results, visit the CMS Web site at www.cms.hhs.gov/CERT.