No matter how often your practice submits claims for evaluation and management (E/M) visits, minor procedures or lab services, coding for these encounters can be confusing. And if the latest CMS Comprehensive Error Rate Testing (CERT) results are any indication, Medicare coding errors are somewhat easy to make.
CMS published its 2024 Medicare Fee-for-Service Supplemental Improper Payment Data report in November, which shared the agency’s insights after reviewing 50,000 claims that had dates of service between July 1, 2022 and June 30, 2023. The overall Medicare error rate of 7.66 percent was slightly worse than last year’s rate of 7.38 percent.
To ensure that your claims don’t end up in next year’s report, check out the common Medicare coding errors that CMS pinpointed in its latest report.
Lab Tests, Established Patient E/Ms Top List of Part B Errors
When it came to Part B improper payments, lab tests were responsible for the highest dollar amount, representing $1.2 billion in improper payments as part of a 27.2 percent error rate. Coming in second among Part B claims were minor procedures, which logged $1.1 billion in improper payments. The majority of the errors in both of these categories were marked as having insufficient documentation.
Third on the list of Part B issues were established patient office visits (99211-99215). These claims were responsible for $1 billion in improper payments, with a 5.5 percent error rate. Unlike the services above, the most common error in this category involved incorrect coding, which usually means either the code level was too low (downcoding) or too high (upcoding). Both are considered improper.
Most of the time, when CMS unveils improper payments in amounts this high, Medicare contractors will begin auditing the coding patterns of individual practices to determine which providers appear to be billing outside of normal patterns. If they see something that catches their eye, they may request additional documentation to confirm the practice is billing properly. Although this doesn’t mean you’re doing anything wrong, if your documentation doesn’t back up your coding levels, you could face requests for reimbursement back, accusations of fraud, or fines. Practices should act now to ensure that their coding is supported in all documentation.
Check Which Specialties Were Most Error-Prone
When CMS reviewers drilled down to evaluate which specialists were most often making errors, they found the following:
Lab tests: Internal medicine providers were responsible for the highest number of improper payments when it came to lab tests, followed by family practice, nurse practitioners, and gastroenterologists.
Minor procedures: General surgeons logged the highest rate of improper payments for minor procedures, followed by internal medicine, family practice and neurologists.
Established patient E/Ms: Internal medicine providers were once again at the top of the list, this time for established patient office visits. Coming in next were nurse practitioners, family practice providers and ophthalmologists.
The overall highest error rates for Part B claims were seen among chiropractors, who logged a 33.6 percent improper payment rate. Coming in next were clinical psychologists, pulmonary disease specialists, cardiac electrophysiologists and nephrologists.
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