Medicare billing problems: Coding mistakes to watch out for

The Centers for Medicare and Medicaid Services (CMS) created the Comprehensive Error Rate Testing (CERT) review program to measure billing problems and improper payments, and identify common problems.

You would think that payers would tend to shy away from claims that have been undercoded-they’re saving money by not identifying these coding errors.

However, the CERT review contractor includes underpayments among the problems they have identified in Medicare billings. 

CERT is also focusing on a number of issues, including unbundling, Magnetic Resonance Imaging (MRI) scans, and annual wellness visits. Physicians should review these common problems to prevent payment snags.

Underpayments

The CERT review contractor determined that a significant number of Medicare fee for service (FFS) claims submitted from July 2010 through June 2011 were underpayments; therefore, the Medicare payments made were improper. An improper payment is an incorrect payment either because it is the wrong amount or it is invalid, based on legal or other requirements. Like overpayments, underpayments count as improper payments.

Examples include coding the  wrong surgery, lower level of Evaluation and Management (E/M) than the documentation supports, and established- instead of a new-patient E/M billed.

Unbundling

The CERT review contractor determined that Medicare made improper overpayments due to unbundling for Part B claims submitted from July 2010 through June 2011. Intentional unbundling is fraudulent billing. The CERT program randomly samples claims and measures improper payments but does not search for fraud. However, if the CERT contractor suspects fraud while reviewing a claim, it must be referred to the appropriate Zone Program Integrity Contractor (ZPIC). The ZPIC develops the case and investigates when appropriate.

Medicare Part A prohibits unbundling. Unbundling specific parts of a beneficiary’s total inpatient care and sending separate claims to Medicare for those tests or treatments is a violation of statute and applicable regulations.

Next: MRI scans and wellness visits

MRI scans

The recovery auditors analyzed claims data for MRI scans and identified incorrect billing of MRI scans not supported by medical necessity based on local coverage determinations (LCDs). 

The recovery auditor found a high percentage of overpayments in the reviewed claims and only one underpayment.

So it’s important to refer to your Medicare carrier’s LCD or the national coverage determination (NCD) for the diagnosis codes that support medical necessity.  If the diagnosis code isn’t on the list, the MRI will be denied.

Wellness visits

Medicare pays for an initial Annual Wellness Visit (AWV), per beneficiary per lifetime.  All subsequent wellness visits must be billed as a subsequent AWV. Initial AWV’s are being billed when a subsequent AWV is appropriate. The HCPCS codes to be used in billing the AWV’s are:

G0438: Annual Wellness Visit, Initial Visit, per beneficiary per lifetime, and

G0439: All subsequent wellness visits must be billed as a subsequent AWV.