Podiatry Coding & Billing Alert

Here are the claims that could be costing your practice well deserved reimbursement.

Your podiatry practice is probably active and bustling every day, but it’s possible that with all that activity, correct coding could be falling through the cracks. Podiatry practices logged a 13.7 percent error rate, according to the latest report from CMS.

You should always pay attention to the medical documentation, so you can avoid making errors in your own practice, says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee.

The backstory:  CMS issued its “2018 Medicare Fee-for-Service Supplemental Improper Payment Data” on November 30 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 an 8.1 percent improper payment rate among Part B claims during 2018.

Dial Into Podiatry Services With Highest Improper Payments

On the list of the services with the most Part B improper payments, CMS reports podiatry visits logged a 13.7 percent error rate, totaling over $188 million in projected improper payments. The insufficient documentation error rate is 78.2 percent. The incorrect coding error rate is 19.5 percent.

Break this down: Take a look at some of the top 20 service types with highest improper payments for DMEPOS from tables D2 and E2:

• Lower limb orthoses — The projected improper payment is over $235 million.
• Diabetic shoes — The projected improper payment is over $104 million.
• Lower limb prostheses —The projected improper payment is over $46 million.
• Orthopedic footwear —The projected improper payment rate is over $8 million.

Some of the top root causes of DMEPOS errors were due to documentation mistakes. So, make sure to avoid the following mistakes that could be costing you well-deserved reimbursement:

• Documentation to support medical necessity or to support the services were »provided or were provided as billed was not submitted.
• A valid provider’s order, or element of an order, was not submitted. 
• The proof of delivery, in entirety or an element, was not submitted. 
• Documentation to support a face-to-face examination or prescription »requirements prior to delivery for certain DME items was not submitted.
• Documentation to support medical necessity of diabetic supplies or medical necessity of high utilization of diabetic supplies was not submitted.
• A signature log of medical personnel to support a clear identity of an illegible signature was not submitted or the provider’s written attestation of the unsigned or illegible signature was not submitted.

See These Medical Necessity Errors

Several podiatry-related services and diagnoses came in on the top “20 Types of Services With Medical Necessity Errors” table, and that means you should pay extra attention to these claims. Other musculoskeletal system and connective tissue OR procedures came in with projected improper payment of over $88 million. The improper payment rate is 22.2 percent. Diabetes logged a projected improper payment of over $54 million. The improper payment rate was 8.4 percent. Lastly, minor musculoskeletal procedures have a projected improper payment of over $52 million. The improper payment rate is 3.9 percent.

Observe These E/M Codes Under Scrutiny

Though incorrect coding is only one category that CMS factors into its overall error rate, the CERT report spotlights the major impact E/M services have on improper payments. The overall impact of all E/M service types on the error rate was 11.9 percent with more than $3.8 billion being improperly paid out to providers for the prominent CPT^® codes, according to Table K1 of the CERT report. Here’s a breakdown of the top three E/M codes causing the biggest problems in the CERT data from Table K1:

1. 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…) ranks first on the CERT report’s E/M worries. With an improper payment rate of 27.2 percent, this confusing CPT^® code accounted for 1.4 percent of the overall error rate and more than $456 million in improper payments.

2. 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 …) took the second spot with an error rate of 4.8 percent and an overall impact of 1.2 percent. This popular E/M office visit code was improperly paid to the tune of $389 million.

3. 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …), which was the number one E/M issue in 2017, was bumped down to third for 2018, and contributed to 1.1 percent of the overall error rate with an individual code error rate of 19.1 percent. Issues with 99233 contributed to $365 million in improper payments.

Heads up:  It’s also important to note that 99223, 99214, and 99233, in addition to others in their code groups, are already in various stages of active prepayment review for the MACs that publish their Targeted Probe and Educate (TPE) topics. And according to CMS guidance, providers should expect more scrutiny of these codes and claims down the line.

The agency plans to increase its “provider outreach and education” with an uptick of “Targeted Probe and Educate initiative[s] to reach individual providers with educational interventions and we’re also enhancing these efforts to allow for flexible and consistent user training,” CMS Administrator Seema Verma said on the improper payment issues.

Resource: To read the full CERT document, visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf.