Top Coding Errors for Physician Practices

Posted by Dana Fuhrman on August 22, 2018

The Centers for Medicare and Medicaid Services (CMS) released the results from their Comprehensive Error Rate Testing (CERT) earlier this year. The results showed a 9.5% overall improper payment rate for 2017, representing $36.21 billion in improper payments. If your practice received some of these improper payments, you could be forced to provide a refund plus incur other additional fees. This article focuses on the most common coding errors identified in the report to help you understand how to prevent them from occurring at your practice.

Top Incorrect Evaluation and Management (E/M) Codes

The E/M code with the highest improper payment rate due to leveling disputes was subsequent hospital care code 99233 at 13.3%. It is projected that Medicare providers will receive $242,001,388 in improper payments for incorrectly assigning this code, which represents the highest level of care for hospital progress notes. The key point to using 99233 is the provider must be sure to meet two of the three components: a detailed history, detailed exam, and medical decision making of a high complexity.  Alternatively, they could spend 35 minutes or more of face-to-face time with the patient. Comorbidities and other underlying diseases cannot be considered when selecting 99233 unless their presence significantly increases the complexity of the medical decision making. Also if the provider chooses to use time to base the assignment of 99233, the time must be documented in the patient’s medical record and the documentation must have sufficient detail to justify the code selection.

The E/M code with the highest improper payment rate due to incorrect coding was hospital discharge day code 99239 at 5.2% with a projected improper payment of $19,582,099. Hospital discharge management code 99239 is a time-based code. The provider must spend more than 30 minutes discharging a patient. This time can include final examination of the patient, discussion about the hospital stay, continuing care instructions for all relevant care providers and preparation of discharge instructions, prescriptions and referral forms. CPT code 99239 can also include care and evaluation for the patient that day that was not continuous. Therefore, the duration of the discharge and support for the duration must be clearly documented in the patient’s medical record.

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Top Upcoded Coding Error

Initial hospital visits have the highest improper payment rate due to upcoding at 19.2%. It is projected that Medicare providers will receive $564,721,063 in improper payment from upcoding initial hospital visits. These codes (99221-99223) are used to bill for initial hospital services and are differentiated by the provider using decision making of either low, moderate or high levels of complexity.  Therefore, it is important to document a history and exam to support the reported level of decision making. Also, if the provider performs a face-to-face visit with the patient on the day of admission, this does not necessarily mean that they can bill for initial inpatient care. If the patient was already admitted by another provider, like their attending physician, the provider should select a subsequent hospital care code (99231-99233) instead.

Top Downcoding Errors

Office and outpatient visits for established patients, code 99212, have the highest improper payment rate due to downcoding at 16.9%. It is projected that Medicare providers lost $75,730,387 because of downcoding office and outpatient visits for established patients. Some providers bill for code 99212 when they should be billing for a code that provides higher reimbursement. Providers must base their code choice on the information gathered, the diagnosis, and on the complexity of the decision making, or on time if more than 50% of the visit was spent counseling the patient and coordinating the care.

Outsourcing your medical coding services to Healthcare Administrative Partners (HAP) can help your practice avoid these top coding errors. HAP uses only expert, certified coders that are specialty specific and dedicated to your account. Coders perform their core tasks within CODIA, our propriety workflow management and coding system that supports compliance and accuracy. Physician eQuery, the integrated communication system in CODIA, enables an exchange between providers and coders to improve documentation and proactively avoid coding errors. Choosing HAP means you will be partnering with a medical coding company that is dedicated to enhancing your reimbursements and reducing your practice compliance risks.

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Dana Fuhrman MSN, RN, RHIA, CCS is the Director, HIS Infrastructure Solutions Sales Management at Healthcare Administrative Partners. 

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