News: E/M errors responsible for nearly 11% of Medicare improper payment rate

A Comprehensive Error Rate Testing (CERT) review showed improper coding and insufficient documentation caused most improper payments for evaluation and management (E/M) services, according to the April 2018 Medicare Quarterly Provider Compliance Newsletter.

The improper payment rate for E/M services billed was 12.1%, accounting for 10.6% of the overall Medicare improper payment rate, Revenue Cycle Advisor reported.  

Insufficient documentation errors occurred when CERT reviewers concluded that services were either incorrectly documented, did not meet the criteria for medical necessity, or were not actually administered by the provider—often because clinicians forgot to include specific documentation elements or did not complete forms in their entirety.

For example, if a clinician billed an E/M service provided in the inpatient setting and submitted a visit note as a record of the service. The visit note would not be enough to support the billed E/M code and the claim would be scored as insufficient, according to Revenue Cycle Advisor.

Other documentation errors were due to providers administering services in a setting other than their own office and failing to document this in the medical record.

In line with these findings, 2017 Medicare Fee-for-Service Supplemental Improper Payment Data shows that E/M codes topped the list of Part B Services determined to have significant upcoding errors, Revenue Cycle Advisor reported. Projected improper payment totals and rates resulting from upcoding of E/M services on claims submitted between July 2015 and June 2016 include:

• $564,721,063, with an improper payment rate of 19.2% for initial hospital visits
• $358,477,409, with an improper payment rate of 2.4% for established patient office visits
• $357,955,465, with an improper payment rate of 12.6% for new patient office visits
• $339,596,019, with an improper payment rate of 6.2% for subsequent office visits 

Editor’s note: This article originally appeared in Revenue Cycle Advisor. For more information on how to avoid errors on claims for E/M services, see the Medicare Claims Processing Manual, Chapter 12, section 30.6 and Chapter 12, section 100.1.1, E/M Services. To learn how CDI can make a difference when it comes to E/M documentation, see ACDIS’ upcoming book on the subject. To read an article about CDI’s role in denials management, click here.