CERT: E/M errors responsible for nearly 11% of Medicare improper payment rate

April 23, 2018
Medicare Web

A Comprehensive Error Rate Testing (CERT) review showed improper coding and insufficient documentation caused most improper payments for E/M services, according to the April 2018 Medicare Quarterly Provider Compliance Newsletter.

The improper payment rate for E/M services billed within a set period was 12.1%, accounting for 10.6% of the overall Medicare improper payment rate, according to the report.  

Insufficient documentation errors occurred when reviewed medical records were inadequate to support reimbursement for billed E/M services. More specifically, CERT reviewers concluded that these services were either incorrectly documented, did not meet the criteria for medical necessity, or were not actually administered by the provider.

In some cases, documentation was insufficient to support the billed services. Insufficient documentation errors occur when clinicians forget to include specific documentation elements or do not complete forms in their entirety. For example, a clinician bills an E/M service provided in the inpatient setting and submits a visit note as a record of the service. The visit note would not be enough to support the billed E/M code and the claim would be scored as insufficient.

Other documentation errors were due to providers administering services in a setting other than their own office and failing to document this in the medical record.

In line with these findings, 2017 Medicare Fee-for-Service Supplemental Improper Payment Data shows that E/M codes topped the list of Part B Services determined to have significant upcoding errors. Projected improper payment totals and rates resulting from upcoding of E/M services on claims submitted between July 2015 and June 2016 include:

  • $564,721,063, with an improper payment rate of 19.2% for initial hospital visits
  • $358,477,409, with an improper payment rate of 2.4% for established patient office visits
  • $357,955,465, with an improper payment rate of 12.6% for new patient office visits
  • $339,596,019, with an improper payment rate of 6.2% for subsequent office visits 

For more information on how to avoid errors on claims for E/M services, see the Medicare Claims Processing Manual, Chapter 12, section 30.6 and Chapter 12, section 100.1.1, E/M Services.

For additional E/M coding and billing considerations, see the Medicare Learning Network Evaluation and Management Services Guide.