Eagle-Eye Your Payors

The Hospitalist. 2009 March;2009(03):

March 1, 2009 | The Hospitalist

FAQs

Q: Incorrect coding errors seem to have the highest error rate in the CERT program’s May 2008 report. What is an example of how this can this occur?

Answer: According to the May 2008 report, a likely example of incorrect coding might involve carrier payment for inpatient consults. More specifically, a Level 4 inpatient consultation (CPT code 99254) valued at about $164 requires adequate documentation of three key components: a comprehensive history, a comprehensive exam, and moderate-complexity medical decision-making (MDM).2 Upon review, it was determined that documentation only supported a detailed history, expanded problem-focused (EPF) exam, and moderate-complexity MDM. Since this documentation is commensurate with CPT 99252, an overpayment of about $87 was requested and collected.

Reasons for this may range from the physician failing to document the complete service to failure of the person handling the request to send in complete information, which resulted in service “downcoding” by CERT staff. In this specific example, it is less likely the provider “overcoded” the encounter, since the medical decision-making was found to be consistent with the requirements of 99254. It is more likely the physician missed a few pertinent elements when documenting the history and physical exam. However, underdocumenting as described here is not counted toward “insufficient documentation” errors, due to the fine line between patient conditions warranting the varying levels of history/exam versus physician inattention to detail.

Outcomes

Individual contractors are notified of improper payments. These include overpayments and underpayments. Unfortunately, contractors do not have to resolve CERT issues involving underpayments, although they are encouraged to do so by CMS.

The CERT program identified overpayments totaling $875,005 during the 12-month reporting period, but collected only $650,418 in overpayments after consideration of appeals that overturned a CERT decision or the provider discontinued business operations. (See Table 1, p. 18, for error rates and Table 2, p. 18, for highest rates of improper payment)

To improve billing compliance and prevent repetitive errors, contractors must implement provider education regarding erroneously paid claims. A contractor may determine the best education method to distribute information about Medicare rules and effectively answer coverage and coding questions.

Some contractors have designed Web-based training modules, Web pages with frequently-asked-questions sections, or local coverage analyses to address contractor-specific errors. Detailed CERT contractor information can be found at www.cms.hhs.gov/ mcd/indexes.asp?from2=indexes.asp&

Due to its successful outcomes, future CMS goals include the continuation of the CERT program. MACs will look more closely at service types based on identified error rates.

Apart from CERT requests, prepayment contractor reviews already exist for most of the services included in Table 2 (p. 18). Timely response is crucial to justify and receive appropriate reimbursement. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare and Medicaid Services. Improper Medicare fee-for-service payments report: May 2008. CMS Web site. Available at: www.cms.hhs.gov/apps/er_report/preview_er_report.asp?from=public&which=long&reportID=9. Accessed Dec. 20, 2008.

2. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association; 2008.