Pulmonology Coding Alert

Plus: Chest physicians among worst offenders when it came to subsequent hospital visit errors.

Pulmonologists see patients in both the office and the inpatient setting, and sometimes that can lead to confusion in terms of the codes that should be selected. Some pulmonology practices appear to have faced issues selecting codes last year, when these specialists logged $128 million in improper payments, according to the latest report from CMS.

The scoop:  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.

Pulmonology Visits Logged Millions in Part B Errors

On the list of the specialties with the most Part B improper payments, CMS ranks pulmonologists high, logging a 10.3 percent overall improper payment rate, totaling over $128 million in improper payments. The majority of those errors (55 percent) were due to incorrect coding, while another 39 percent occurred because of insufficient documentation, and the remaining six percent stemmed from no documentation at all.

Drilling down to the data, pulmonologists also ranked high on the list of providers that had the most errors when it came to subsequent hospital visits. With a 14.6 percent improper payment rate in this category, physicians treating pulmonary disease were responsible for some $44 million in improper payments just for their subsequent hospital care services. Only four other specialties (internal medicine, family practice, cardiology, and psychiatry) logged higher improper payment amounts for subsequent hospital care.

Tighten Your Subsequent Visit Coding

If you code subsequent hospital visits, make sure you know the components of each code level (99231-99233) so you can select the right code based on the documentation. If your practice routinely reports the same code frequently, or if you simply suspect that you aren’t coding subsequent hospital visits accurately, you should perform a chart review. Take a random chart sampling, and on each file, you should determine the history, exam, and medical decision-making (MDM) levels, then select which code the documentation supports.

You may be surprised what you find. “Patient feeling OK today” does not even support 99231 -- but some coders have reported seeing documentation as sparse as this in physicians’ notes during subsequent hospital visits.

Tactic: If the physicians fail to see the importance of such a review, you should place the number of visits they undercoded into a graphic format to show them how much money they left on the table. If the opposite is found, then share the amount with the doctors and tell them that they must return that amount back to the MAC due to overpayments.

Don’t Ignore CERT Requests

Reading about the CERT results may prompt you to wonder what you’d do if the government requested your records as part of a CERT audit. You can respond to a CERT request in several ways, according to Michael Hanna, MPA, CDME,  provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar. Take a look at Hanna’s advice and other expert tips on CERT correspondence:

• Fax: This is the preferred method, Hanna says. “Always include the barcode sheet as part of your fax package. This simply marries the documentation you’re submitting with that particular date of service the CERT contractor has chosen for a review.”
• esMD: The electronic submission of medical documentation system (esMD) is another option. With this method, you use the gateway you contracted with and follow standard procedure.
• Postal Mail: “If it’s a sizeable amount of documentation, or you’ve already saved it to a CD, you can mail it in,” Hanna adds. If you send a CD, it can only contain TIFFs or PDFs and should be encrypted in line with HIPAA Security Rule standards, according to CERT Review contractor AdvanceMed.
• Email: You may send an encrypted email, but “if [it’s] encrypted, the password and CID# must be provided” with a follow-up phone call or fax, advises AdvanceMed.

Don’t miss: You can make extension requests by telephone only.

Caution: Normally, the CERT contractor grants extensions only in extreme circumstances such as natural disasters like hurricanes, tornadoes, and ongoing fires, according to Hanna.

“But, if you are simply waiting on medical records from the physician, it is possible the CERT contractor may not grant that extension,” Hanna acknowledges. “If that is the case, you should always send the CERT contractor what you have available, and then if they disagree or find something missing or not valid, you do have appeal rights.”

Any claim errors the CERT contractor finds will result in a revised Medicare admittance advice where they will deny that claim and an overpayment demand where they ask you to repay the money, Hanna cautions.

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.