Be Wary of Erratic E/M Billing and Coding
The latest CERT (Comprehensive Error Rate Testing) results of CMS reveal that it had paid a sum of $7.
8 billion improperly in the year 2011.
This has resulted in a shocking 9.
2% Part B error rate.
Part B (Medical Insurance) of Medicare covers outpatient care, certain doctors' services, medical supplies, and preventive services.
The majority of these inaccurate payments were overpayments to Part B practices, and less than $1 billion were in underpayments.
It was found that compared to other Part B services, E/M services were fifty percent more likely to contain errors.
Evaluation and Management services accounted for more than twelve percent of all Medicare errors in the year 2011.
Errors stemmed mostly from:
1% error rate CMS found in physicians reporting glucose monitoring supplies.
CMS made inappropriate payments on account of either insufficient physician documentation to substantiate medical necessity; the physician failing to indicate the number of times the patient's glucose level needed to be tested per day; or the physician not documenting the diabetic condition and the necessity of monitoring glucose at the billed frequency.
Apart from this, physicians proved to be rather careless in billing nebulizers.
In this category, CMS found a 57.
4% error rate.
In many cases, physicians had failed to provide documentation regarding the type of solution to be used with the nebulizers, and the prescribed frequency.
Note the Following Important Points
8 billion improperly in the year 2011.
This has resulted in a shocking 9.
2% Part B error rate.
Part B (Medical Insurance) of Medicare covers outpatient care, certain doctors' services, medical supplies, and preventive services.
The majority of these inaccurate payments were overpayments to Part B practices, and less than $1 billion were in underpayments.
It was found that compared to other Part B services, E/M services were fifty percent more likely to contain errors.
Evaluation and Management services accounted for more than twelve percent of all Medicare errors in the year 2011.
Errors stemmed mostly from:
- Providers reporting the wrong E/M code
- Insufficient documentation for the billed E/M services
- Mistakes in billing supplies
1% error rate CMS found in physicians reporting glucose monitoring supplies.
CMS made inappropriate payments on account of either insufficient physician documentation to substantiate medical necessity; the physician failing to indicate the number of times the patient's glucose level needed to be tested per day; or the physician not documenting the diabetic condition and the necessity of monitoring glucose at the billed frequency.
Apart from this, physicians proved to be rather careless in billing nebulizers.
In this category, CMS found a 57.
4% error rate.
In many cases, physicians had failed to provide documentation regarding the type of solution to be used with the nebulizers, and the prescribed frequency.
Note the Following Important Points
- Medicare will cover only those services that are reasonable and considered necessary for the diagnosis/treatment of the illness or to improve functioning.
- Physicians must not bill a higher level, more expensive code when only a lower level, less expensive code is needed.
- Physicians must accurately and thoroughly document that the particular E/M service was necessary and reasonable.
If necessary information is missing in a claim, it will not be reimbursed. - Physicians must use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document the medical record with the proper clinical information.
- CMS has introduced new E/M codes for visits in rest homes and nursing facilities based on the AMA coding changes.
- CMS discontinued payment of E/M codes for inpatient/outpatient consultations.
It has required that physicians bill for these consultations using one of the remaining E/M codes that will accurately indicate the complexity of the visit and the place of service.
Source...