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Comprehensive Error Rate Testing (CERT) May 2007 Report — One Top Reason for Errors: Services Incorrectly Coded

The May 2007 Comprehensive Error Rate Testing (CERT) Report was published on May 15, 2007 on the CERT website, https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.htmlExternal Websiteindicating that the national paid claims error rate for this reporting period is 4.2%, which equates to $10.4B.

Services incorrectly coded stood out as one of the top reasons for CERT errors. Specifically, the majority of these incorrectly coded claims relate to incorrectly coded Evaluation and Management (E&M) services in which the level of E&M service billed is not supported by the documentation submitted pertaining to the patient's condition and the key components of the E&M service.

This high rate of incorrectly coded Evaluation and Management (E&M) services generally implies that providers may be in need of education or review on how to properly code an Evaluation and Management (E&M) visit. Selecting the appropriate Evaluation and Management (E&M) code should be based upon medical necessity and the content of the service provided to the patient which needs to be supported by documentation in the patient's medical record.

It is important to remember:

  1. Documentation of the key components – the History, Physical Exam, and Medical Decision Making – should support the level of the E&M service billed.
  2. Per the Medicare Claims Processing Manual, Chapter 12, the selection of the level of Evaluation and Management service may be based on the duration of Coordination of Care and/or Counseling. When counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. The physician must document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
  3. All billed E&M services must be based only on activities that are reasonable and necessary for the diagnosis or treatment of illness or injury (SSA 1862(a) (1) (A). "... Documentation of History, Physical Examinations and Medical Decision Making, should not be performed or billed at levels greater than needed for the patient's condition."
  4. As documented in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of Evaluation and Management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

IT IS IMPORTANT TO NOTE:

  • When reviewing an E&M service, the reviewer will first establish medical necessity, and then the level of service needed based on the documentation submitted.
  • Legibility of the documentation may also affect how a reviewer is able to clearly interpret and define the level of the E&M code billed. If legibility is poor, E&M services may be down-coded whereas presentation in a readable format may not result in downcoding.

In summary, we recommend:

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