Question

Medical Coding and Billing

In a word document write (600 - 900 Words) Using APA Referencing style, Discuss the following:

The Centers for Medicare and Medicaid Services (CMS) released the results from their Comprehensive Error Rate Testing (CERT) earlier this year 2018. The results showed a 9.5% overall improper payment rate for 2017, representing $36.21 billion in improper payments. If any medical practice received some of these improper payments, They could be forced to provide a refund plus incur other additional fees.

Discuss on general basis, the most common coding errors and how to prevent them from occurring at any health care practice.

Answer 1

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.

On general basis, the most common coding errors identified in the report to help us understand how to prevent them from occurring at any health care practice which are given as :

(i) 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 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.

Therefore, the duration of discharge and support for the duration must be clearly documented in the patient’s medical record.

(ii) 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.

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.

(iii) 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.