CMS’s 2015 CERT Report Reveals Dangers of Upcoding and Downcoding

CMS’s 2015 CERT Report

Yes, upcoding, or assigning an inaccurate code to a medical claim to increase reimbursement, equals fraud. But when you think about it, downcoding is just as bad as upcoding. Many practices think that if they downcode, or intentionally bill charges at a lower level than their documentation supports, they’ll stay off auditors’ radar. But the opposite is true—reporting only low-level E/M codes will get the payer’s attention, because its reviewers will wonder why you never offer high-level evaluations to your patients. And your practice will miss out on getting the payment it deserves for the work your providers perform.

CERT Reports: Providers Underbilled by More than $1 Billion in 2015

The Centers for Medicare & Medicaid Services (CMS) released its annual Comprehensive Error Rate Testing (CERT) results recently with startling news: Providers left more than $1 billion on the table last year because of chronic downcoding of claims. For example, for established office visits, the CERT results showed practices forfeited $209.3 million on codes 99211-99215. Other commonly downcoded services included coronary artery bypasses without cardiac catheterization; nursing home visits; subsequent hospital visits; and major joint replacements. All tolled, practices missed getting paid a staggering $1.17 billion last year — that’s $1.17 billion that they rightfully deserved.

The total dollar amount of improper payments CMS found on its 2015 CERT testing is mindboggling: $11.5 billion, due to both undercoding and overcoding. Lab tests had a 39.0 percent error rate, initial hospital visits a 19.1 percent error rate, and chiropractic visits were billed improperly a jaw-dropping 51.7 percent of the time.

You won’t be surprised to learn that most of the CERT errors had to do with insufficient documentation, causing 65.4 percent of the incorrect payments. The next most common issues were medical necessity errors at 19.7 percent, incorrect coding at 10.5 percent, and no documentation at all, at 1.3 percent.

You can find CMS’s 2015 CERT report here.

And About That Documentation …

Remember, if you’re downcoding office visits, you’re committing coding errors — your documentation supports the level of service you provided, and you must bill for what your documentation indicates. Always determine the criteria for the service you provided, then select the most accurate code based on the documentation. If your medical records support the code, don’t be worried about sometimes billing a higher code than what you’re used to reporting.

Here’s an example of a common documentation and coding error that led to upcoding. Say a provider reports 99245, (Office consultation for a new or established patient, which requires these 3 key components…). For this code, physician documentation must indicate medical decision making of high complexity, with a comprehensive patient history and physical exam. But if you reported this code with accompanying documentation indicating an “unremarkable” history and a “problem-focused examination of the abdomen,” the payer would deny the claim because documentation supports only a low complexity of medical decision making. You would have to resubmit, using the straightforward medical decision-making code 99241 (Office consultation for a new or established patient, which requires these 3 key components…).

What Do You Think?

When I see figures like $1,170,000,000 I end up counting zeroes on my fingers to make sure I wrote “billion” correctly. I’m sure many practices undercode routinely just out of fear of incurring the wrath of auditors, but wow, what a lot of money to leave behind, and the auditors are still on your tail! What do you think? Tell us in the comment box below.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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