Every coder knows that although most providers perform evaluation and management (E/M) services nearly every day, coding these visits aren’t necessarily straightforward. That fact is backed up by data in the latest CMS report, which notes that established patient E/M codes 99211-99215 were riddled with errors, most of which were due to upcoding.
The facts: CMS published its 2023 Medicare Fee-for-Service Supplemental Improper Payment Data report on December 7, 2023, which shared the agency’s insights after reviewing 45,310 claims that had dates of service between July 1, 2021 and June 30, 2022. The overall Medicare error rate of 7.38 percent was better than last year’s rate of 7.5 percent.
To ensure that your claims don’t fall into the coding traps that these services did, check out the common Medicare coding errors that CMS identified.
E/M Codes Plagued by Upcoding
When it came to Part B claims, CMS ranked the services in order of which categories were responsible for the highest dollar amount in improper payments. Coming in first were established patient E/M visits (99211-99215), which represented $1.1 billion in improper payments. Office visits for new patients (99202-99205) weren’t far behind, as they were responsible for $319 million in improper payments. When combined, the new and established patient E/M codes accounted for nearly $1.5 billion in Medicare coding errors.
Coming in next on the list after E/M codes among Part B improper payments were lab tests, followed by minor procedures.
Typically, when CMS uncovers improper payments in high dollar amounts like these, Medicare contractors will start taking a closer look at the coding patterns of individual practices. If reviewers see claims that fall outside of the averages, they could ask for documentation to back up the services billed and scrutinize that office’s coding to find line-item errors. Once found, these types of Medicare coding errors can cause a chain reaction, sparking requests for reimbursement back, accusations of fraud, and even serious fines.
CMS classified each incorrectly coded E/M service based on the types of error observed, with the most common drivers below.
Upcoding
When it came to established patient office visits, most of the Medicare coding errors involved upcoding, with CMS noting that the “documentation supported a lower level of E/M service than what was billed.”
For instance, suppose the physician saw an established patient, documented 15 minutes total time spent and reported 99213. Because 15 minutes of total time only justifies reporting 99212 and not 99213, this would be considered an upcoded claim.
Avoid this error: To ensure you don’t make coding mistakes on your claims, always review the descriptors, local coverage determinations and CPT guidelines to understand exactly which services are described by each code. If you’re ever confused about which code applies to the service your provider performed, consult the provider rather than trying to pick a code that appears to be “close enough.”
Downcoding
Coming in second on the list of most common established patient E/M errors was downcoding. In these instances, the “documentation supports a higher level of E/M service than what was billed.”
For example, suppose the provider documents a high level of decision-making (MDM) for an established patient, and reports 99214. The documentation does not include any mention of how much time was spent. Because 99214 should be reported for a moderate level of MDM and this provider performed high MDM, auditors would consider this a downcoded claim, which justifies the higher-level code 99215.
Insufficient Documentation
This error category means the medical records did not support the medical necessity of the service billed.
For example, suppose the documentation states, “Saw this established patient for follow-up to Dec. 3 visit,” with no further information. This note fails to address the patient’s chief complaint, an explanation of what was performed, or how long the doctor met with the patient. That means the payer will ask for the reimbursement back for what they paid the practice for this service.
Avoid this error: Never submit a claim if the documentation doesn’t support the codes that the doctor selected in the electronic health record or on the superbill. Instead, query the provider and ask them to create an addendum to the documentation if possible, so it’s thorough enough to stand up to an audit and does not trigger accusations of Medicare coding errors.
Unsure of the basics surrounding correct coding? Get the facts from expert Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, during her 75-minute online training event, 2024 CPT Code Changes: Accurately Meet Jan 1. Deadline. Sign up today!
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