Well, here we are at the beginning of the fourth quarter of 2024 and CMS has graced us with their annual as I call it “The Come to Jesus Report”, as it highlights ALL the Coding, Billing, Documentation errors, and Service Types, across all states. It is a good read, and I strongly recommend it to all Practice Administrators, Directors of RCM, Coding, Billing, Auditing, and Compliance, at the very least. It’s a good time to dust off the old Compliance manual (which hopefully you have) and check in on how your providers are doing and the coding, billing, and auditing teams.
This article will focus on Evaluation and Management codes and touch on some others that are part of the “Top Five” on the report, which will provide insight into what codes landed as the most frequently billed and which codes had the most errors of 2023. The Centers for Medicare (CMS) measures the Medicare Fee For Service (FFS) improper payment rate through the CERT program and the 2023 Medicare FFS improper payment rate included claims submitted during the 12 months from July 1, 2021, through June 30, 2022.
To break down this process the folks at CMS use a sampling process for CERT that follows a service level stratification plan into what is called a “universe” and approximately 100 claims are sampled in the universe per claim type and are then reviewed, which leads to an improper payment rate, which ultimately leads to the total payments made. Below is the overall Accuracy Rate and Improper Payment Rate for this year’s report:
- Roughly 7.38% were deemed Improper Payments, which means a 92.62% Accuracy Rate. CMS requires 95% accuracy overall for Coding and Billing of submitted claims.
Now we must factor in that due to the documentation requirements that changed in 2021 (which were supposed to un-burden providers). Calendar year (CY), 2022 was the second year that providers were supposed to be actively utilizing the new E&M guidelines from the AMA/CPT/CMS, which are now based on either Time or Medical Decision Making (MDM). This impacted many clinicians across a wide range of specialties.
The billed level of service will also vary by specialty as the patient demographic varies. An Oncologist who sees complicated cases will tend to bill higher E&M visits versus say a pediatrician, who does not see the same type of cases. That does not mean a pediatrician wouldn’t be justified in billing a higher-level E&M, if the MDM documentation supports it or if they billed based on time.
Other coding issues that can cause incorrect coding errors are if a provider reports a code that is higher or lower than what the documentation supports. For example a provider spent and documented 20 minutes for an established patient with COPD and 99215 is submitted, it would be considered up-coded, as 99215 requires at minimum, 40 minutes of total time with the patient to get credit for the level five visit. A payer would down-code this if they caught it on the front end, to a 99213 and record it as a coding error. Additionally, they could also ask for a refund or offset of payment, in a post-payment review, if it was missed and paid out on the front end.
So what are the Top Five Common Causes of Improper Payments you ask? CMS has kindly put them into some terrific graphs and as you can see below, the Top Five are as follows:
Insufficient Documentation led the pack with an astounding 62.8%
Medical Necessity came in a strong second with 15%
Incorrect Coding came in with 11.6%
My favorite “other” at 6.9%
Last but definitely not least is No Documentation with 3.7%
Ensure that all claims are bulletproof with concise and supportive documentation
When I educate providers, one of the first things I discuss is how to bulletproof the documentation. In other words, if you were called to the witness stand, would the visit note hold up or would you go down flames? Unfortunately, this year’s reports appear that many would go down in flames and the lesson here is that we can use this information to improve. Let’s take a look at the data for CMS Part B service codes and see where exactly improvement is most needed as we head into 2025.
2023 E&M/CPT Code Report Stats:
The most reported Evaluation & Management codes for outpatient/office visits were 99214 for established patients and 99204 for new patients.
Most reported Part B service coding errors for office visits landed with insufficient documentation, lab tests, and minor procedures.
99214 & 99204 Focal Points in most CMS Audits
The most recent Centers for Medicare & Medicaid Services (CMS) utilization data (from FY 2022) indicate that Medicare Part B paid for more instances of 99214 (Office or other outpatient visits for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded) than any other outpatient office visit codes. 99204, Office or other outpatient visits for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision-making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded) was the most frequently billed.
CLOSING THOUGHTS
When you consider that Medicare allowed 98.5 million claims for 99214 in 2022, and 12.3 million claims for 99204 in 2022, it is easy to see why these two E&M codes are targeted in most CMS/government audits. Additionally, E&M Codes 99213/99203 came in close behind 99214/99204 with 73.6 million paid claims for 99213 and 99203 following up with 9.6 million claims. One of the key differences is that Level 3 E&Ms – 99213/99203 are often under-coded vs 99214/99204 being up-coded and for certain specialties, once they see a new patient, i.e., either 99203 or 99204, they can’t bill for another new patient visit for the same patient, until three (3) years have passed, from the initial new patient visit.
TAKEAWAYS:
Bulletproof Documentation with Providers – Ongoing
Perform ongoing Coding and Billing Reviews
Check the CERT reports on your Medicare Administrative Contractor’s MAC’s website – https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/who-are-macs#MapsandLists
Perform Compliance Plan Quarterly
Review Payer Denials and Requests – Ongoing
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/data-research/statistics-trends-and-reports/medicare-fee-for-service-parts-a-b
https://www.cms.gov/files/document/2022-medicare-fee-service-supplemental-improper-payment-data.pdf
https://www.cms.gov/files/document/2023medicarefee-servicesupplementalimproperpaymentdatapdf.pdf
MBR AAPC/NAMAS
Director of Compliance and Education, ZENMED Solutions INC.
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