Coding and Documentation - What Primary Care and Florida Have in Common

With the recent release of CMS’s 2023 Improper Payment Report came some interesting results, of note are where Primary Care and the state of Florida land on Error Rates. The report indicates that after a thorough review by CMs, Primary Care was at the top of the list for most frequent Part B Medicare errors in comparison to the national average. The data CMS reviewed included over 45,000 claims for dates of service covering July 1, 2021, through June 30, 2022. After CMS Auditors completed their review, Primary Care (and specialties under that umbrella), clearly led the pack with Part B errors.

Here is the breakdown:

Overall, the Part B Average error rate for all Provider types is upwards of 10.0%.
Family practice rolled in at nearly 14% in errors
Internal medicine came in hot with a close to 13% error rate.
With the combined extreme volume of Internal medicine claims, they took the lead in overall improper payments and errors at 3.2%, only Clinical Labs had a higher percentage of overall improper Part B payments and errors coming in at 3.4%

Of note, Florida, and California stood out on the CMS report as states with the greatest number of overall errors and improper payments. It seems that Florida providers ranked in with 10.8% of improper payments, with California coming in with 10.7%. Closely following both Florida and California are Texas, Pennsylvania, and New York. Collectively, all these states submitted a higher number of claims than other states.

Why Be Concerned About Improper Payments?

Well from a legal perspective, providers are responsible for any claims that are submitted for reimbursement to a payer, when their credentials and National Provider Identifier (NPI) number are listed on it. When a provider is enrolled with a payer, whether it is Medicare, Medicaid, Blue Cross Blue Shield, or another Commercial payer, part of the paperwork involves signing an attestation agreement, which obligates a provider to submit accurate claims. This means that in the event of an audit and there are improper payments found, you will be held responsible by CMS. On the back of the CMS 1500 form (electronic version as well), there is specific verbiage that says the provider attests to the accuracy of the codes submitted. This means that regardless of whether the provider or coder/biller, assigns the codes, at the end of the day, CMS or other payer, will question the provider if there are any issues with a claim. CMS and other payers, hold the provider accountable for all claims submitted with their NPI number.

Most providers do not submit claims with errors intentionally, but that does not eliminate a provider from being held accountable and having overpayments recouped. Medicare’s Evaluation and Management Services guide which is published through Medlearn Matters (MLN), states the following:

CMS says “When billing for a patient’s visit, the provider should choose codes that best characterize the services provided during the visit. A Coding or Billing specialist or alternate source may review your documentation before you send the claim. A reviewer may help you choose codes that show the services you give to the patient.”

Every Claim must ensure the following:

Each claim shows all billed services with codes (CPT/DX/HCPCS/EM, MODIFIERS, etc.)
The medical record documentation is clear and supports the services you are billing

Unbundling
LCDs are being adhered to

The Way Forward:

Most providers want to know how they are doing, especially if they are reimbursed based on an RVU methodology. It is important to provide what I call a “Down-coded Chart Report,” every week, to show them why their charts are not meeting the levels they are choosing. It is an excellent opportunity to provide them with education on how to document better to support what they assign and how they treat a patient. The devil is always in the details and in many cases, there is either too much detail that has nothing to do with the actual visit issues or there is not enough detail to support the level. I always say “Bulletproof” your documentation, I feel like I can’t say it enough.

Provider Tip:

Go back and start reading 1-2 encounters per day, see if what you think you wrote, actually tells the whole story for that patient and conveys to a coder or biller or CMS, support for what is being billed under your NPI.

Happy Coding!

Resources:

https://www.medcentral.com/coding-reimbursement/the-most-billed-and-most-error-prone-codes-of-2023

https://www.cms.gov/files/document/2023medicarefee-servicesupplementalimproperpaymentdatapdf.pdf

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/mln-publications-items/cms1243514

https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-fee-for-service-parts-a-b

https://codingintel.com/responsible-coding-physician-services-medical-provider-coder/#:~:text=The%20Medical%20Provider%20or%20the,accurate%20claims%20will%20be%20submitted.