E&M Coding and Billing Still Trip Up Practices

Would your Medicare evaluation and management (E&M) coding, and “incident to” billing stand up to close scrutiny?

A report from the Centers for Medicare & Medicaid Services (CMS) indicates these claims are among the types that Medicare commonly overpays in error. CMS wants to stop the overpayments.

CMS annually evaluates a random sample of Medicare claims to determine if its contractors paid the claims properly under Medicare coverage, coding, and billing rules. Through its Comprehensive Error Rate Testing (CERT) program, CMS calculates Medicare Part A and Part B improper payment rates (mostly overpayments to physicians and providers).

This information tells CMS which areas to improve. For example, partly because of a policy revision to the home health face-to-face encounter requirements, the home health improper payment rate decreased from 59 percent in 2015 to 42 percent in 2016.

In Texas, Medicare is paying out a lot of money — about $4 billion — it shouldn’t be paying under its own rules. Texas ranked second in dollar amount for combined Part A and Part B improper payments in 2016 (and ranked first in percentage of improper payments, at 17.5 percent).

In 2016, the nationwide improper payment rate for Medicare Part B (excluding durable medical equipment, prosthetics, orthotics, and supplies) was 11.7 percent, or $10.9 billion. More than two-thirds of the erroneous payments (68.2 percent) resulted from documentation insufficient to support the services billed or the level at which they were billed, or to support medical necessity. In some cases, a required documentation element of the claims was missing.

E&M Services

The improper payment rate in Part B for E&M services was particularly notable at 14.3 percent, resulting mostly from incorrect coding and insufficient documentation. For example:

• Documentation supported an E&M code different from the one billed.
• Records submitted lacked a physician signature.
• Physicians provided services in settings other than their own office and did not submit records maintained by hospitals or other facilities.

Incorrect coding also can occur when someone other than the billing provider or supplier performed the service, the billed service was unbundled, or a beneficiary was discharged to a site other than the one coded on a claim. Incorrect coding figured highly in improper payments for established patient office visits, and initial and subsequent hospital visits. The specialties of internal medicine, family practice, and cardiology accounted for about half of these payments.

What Does This Mean to You?

For starters, if you are selected for a CERT audit and it uncovers an overpayment, Medicare will recoup that payment. In addition, Medicare contractors like Novitas Solutions are under pressure to reduce error rates. CERT results reveal which types of claims need closer scrutiny and where you might start to see more denied claims.

Novitas has some tools in its Evaluation & Management Center to help practices code correctly the first time, including:

• E&M Interactive Score Sheet helps you select the right E&M codes;
• Printable specialty exam score sheets for E&M coding; and
• Incident to Self-Service Tool, a decision tree to help you apply the CMS “incident to” requirements when billing for services of nonphysician practitioners (NPPs).

See also:

• CMS’ poster with coding guidance for E&M documentation of CPT code 99215 (established office visit),
• CMS’ Evaluation and Management Services guide,
• Novitas’ webpage, Incident to Services in the Office Setting, and
• Incident to Billing Criteria on the TMA website.

If you have questions about billing and coding or Medicare policies, contact a TMA reimbursement specialist at paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955.

Billing for Nonphysician Practitioners Seminar

Learn how to bill correctly for NPP services at TMA’s new Billing for Nonphysician Practitioners seminar in a city near you through Sept. 26. You also can tune in to the live webcast on Sept. 20. Review the rules with TMA consultant Brad Davis and study example scenarios so you can code services the right way. Register now.

Certified professional coders and auditors at TMA Practice Consulting can help you ensure your coding and medical record documentation follow Medicare and other payers’ guidelines for appropriate billing. To learn more about an in-depth review, a check-up, or on-site training, call (800) 523-8776 or email practice.consulting[at]texmed[dot]org.

Published Aug. 30, 2017

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