{"id":1852,"date":"2024-09-27T16:08:23","date_gmt":"2024-09-27T16:08:23","guid":{"rendered":"https:\/\/zenmedinc.com\/blog\/?p=1852"},"modified":"2024-12-07T13:06:49","modified_gmt":"2024-12-07T13:06:49","slug":"coding-and-documentation","status":"publish","type":"post","link":"https:\/\/zenmedinc.com\/blog\/coding-and-documentation\/","title":{"rendered":"Coding and Documentation &#8211; What Primary Care and Florida Have in Common"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"1852\" class=\"elementor elementor-1852\">\n\t\t\t\t<div class=\"elementor-element elementor-element-8a54a8e e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"8a54a8e\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2efc103 elementor-widget elementor-widget-text-editor\" data-id=\"2efc103\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><span style=\"color: #000000;\">With the recent release of CMS\u2019s 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.<\/span> <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Here is the breakdown:<\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Overall, the Part B Average error rate for all Provider types is upwards of 10.0%. <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Family practice rolled in at nearly 14% in errors <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Internal medicine came in hot with a close to 13% error rate. <\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><span style=\"color: #000000;\">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%<\/span> <\/span><\/span><\/p><\/li><\/ul><p><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter wp-image-1860 size-full\" src=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/10\/improper-payments.jpg\" alt=\"\" width=\"608\" height=\"686\" \/><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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.<\/span><\/span><\/p><p><img decoding=\"async\" class=\"aligncenter wp-image-1862 size-full\" src=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/10\/improper-payments-2.jpg\" alt=\"\" width=\"554\" height=\"190\" \/><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Why Be Concerned About Improper Payments?<\/b><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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. <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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\u2019s Evaluation and Management Services guide which is published through Medlearn Matters (MLN), states the following:<\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">CMS says \u201cWhen billing for a patient\u2019s 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.\u201d <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Every Claim must ensure the following: <\/b><\/span><\/span><\/p><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Each claim shows all billed services with codes (CPT\/DX\/HCPCS\/EM, MODIFIERS, etc.)<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">The medical record documentation is clear and supports the services you are billing <\/span><\/span><\/p><\/li><\/ul><ul><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Unbundling<\/span><\/span><\/p><\/li><li><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">LCDs are being adhered to <\/span><\/span><\/p><\/li><\/ul><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>The Way Forward:<\/b><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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 \u201cDown-coded Chart Report,\u201d 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 \u201cBulletproof\u201d your documentation, I feel like I can\u2019t say it enough. <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Provider Tip:<\/b><\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">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. <\/span><\/span><\/p><p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Happy Coding!<\/span><\/span><\/p><p><span style=\"color: #000000;\"><b>Resources:<\/b><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.medcentral.com\/coding-reimbursement\/the-most-billed-and-most-error-prone-codes-of-2023\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.medcentral.com\/coding-reimbursement\/the-most-billed-and-most-error-prone-codes-of-2023<\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #467886;\"><u><a href=\"https:\/\/www.cms.gov\/files\/document\/2023medicarefee-servicesupplementalimproperpaymentdatapdf.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><span style=\"color: #0000ff;\">https:\/\/www.cms.gov\/files\/document\/2023medicarefee-servicesupplementalimproperpaymentdatapdf.pdf<\/span><\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cms.gov\/outreach-and-education\/medicare-learning-network-mln\/mlnproducts\/mln-publications-items\/cms1243514\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cms.gov\/outreach-and-education\/medicare-learning-network-mln\/mlnproducts\/mln-publications-items\/cms1243514<\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.cms.gov\/data-research\/statistics-trends-and-reports\/medicare-fee-for-service-parts-a-b\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/www.cms.gov\/data-research\/statistics-trends-and-reports\/medicare-fee-for-service-parts-a-b<\/span><\/span><\/a><\/u><\/span><\/p><p><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/codingintel.com\/responsible-coding-physician-services-medical-provider-coder\/#:~:text=The%20Medical%20Provider%20or%20the,accurate%20claims%20will%20be%20submitted\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">https:\/\/codingintel.com\/responsible-coding-physician-services-medical-provider-coder\/#:~:text=The%20Medical%20Provider%20or%20the,accurate%20claims%20will%20be%20submitted<\/span><\/span><\/a><\/u><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">.<\/span><\/span><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>With the recent release of CMS\u2019s 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<\/p>\n","protected":false},"author":2,"featured_media":1859,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[15],"tags":[52,49,46,48,51,50,47],"class_list":["post-1852","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing","tag-cms","tag-cmss-report","tag-coding-and-documentation","tag-florida","tag-improper-payment-rates","tag-part-b-medicare-errors","tag-primary-care"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Coding and Documentation - What Primary Care and Florida Have in Common - ZenMed Solutions Inc<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/zenmedinc.com\/blog\/coding-and-documentation\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Coding and Documentation - What Primary Care and Florida Have in Common - ZenMed Solutions Inc\" \/>\n<meta property=\"og:description\" content=\"With the recent release of CMS\u2019s 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\" \/>\n<meta property=\"og:url\" content=\"https:\/\/zenmedinc.com\/blog\/coding-and-documentation\/\" \/>\n<meta property=\"og:site_name\" content=\"ZenMed Solutions Inc\" \/>\n<meta property=\"article:published_time\" content=\"2024-09-27T16:08:23+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2024-12-07T13:06:49+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/10\/AUDIT-PIC-11.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"800\" \/>\n\t<meta property=\"og:image:height\" content=\"533\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Holly Cassano\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Holly Cassano\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\/\/zenmedinc.com\/blog\/coding-and-documentation\/#article\",\"isPartOf\":{\"@id\":\"https:\/\/zenmedinc.com\/blog\/coding-and-documentation\/\"},\"author\":{\"name\":\"Holly Cassano\",\"@id\":\"https:\/\/zenmedinc.com\/blog\/#\/schema\/person\/159df9fb285b8cbc7f290d96977cb730\"},\"headline\":\"Coding and Documentation &#8211; 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