Don't have a TCI SuperCoder account yet? Become a Member >>

Gastroenterology Coding Alert

Part B Reimbursement:

CMS: Gastroenterologists Logged $79 Million in Improper Part B Payments

Plus: Upper GI procedures were a source of problems.

With so many compliance facts and regulations to follow, it’s not surprising that some practices can lose sight of correct coding and billing from time to time. That appears to have been the case in 2018, when GI practices logged almost $80 million in improper payments, according to the latest report from CMS.

The backstory:  CMS issued its “2018 Medicare Fee-for-Service Supplemental Improper Payment Data” on November 30 as part of its Comprehensive Error Rate Testing (CERT) program. The report breaks down the biggest errors among Medicare claims, and covers the causes of the improperly paid charges. Overall, the government found an 8.1 percent improper payment rate among Part B claims during 2018.

GI Visits Logged Millions in Part B Errors

On the list of the specialties with the most Part B improper payments, CMS ranks gastroenterologists high, logging a 10.6 percent provider compliance improper payment rate and a 5.7 percent overall improper payment rate, totaling over $79 million in improper payments. The majority of those errors (68 percent) were due to incorrect coding, while another 32 percent occurred because of insufficient documentation.

Avoid These Common Errors

Although many practices may be focusing on the millions of dollars in errors recorded for GI practices, keep in mind that not all of them were due to overcoding. Many of the errors involved undercoding and underpayments, which meant that these doctors actually deserved more money than they billed. Of course, these types of problems are still considered errors and “incorrect coding,” so it would be best to put checks in place to prevent these issues going forward.

The stats: According to the report, about $202 million of visits coded as 99213 were underpaid, while $87 million visits coded as 99212 were underpaid, representing a 22.2 percent underpayment rate.

On the flip side, some $356 million in Part B payments for 99214 were marked as overpayments, logging a 4.4 percent overpayment rate for this code.

Upper GIs: CMS reported that nearly $6.5 million in Part B claims were improperly paid for upper GI endoscopy. In addition, CMS marked another $6.4 million in improper payments for lab services by gastroenterologists.

Don’t Ignore CERT Requests

Reading about the CERT results may prompt you to wonder what you’d do if the government requested your records as part of a CERT audit. You can respond to a CERT request in several ways, according to Michael Hanna, MPA, CDME,  provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar. Take a look at Hanna’s advice and other expert tips on CERT correspondence:

  • Fax: This is the preferred method, Hanna says. “Always include the barcode sheet as part of your fax package. This simply marries the documentation you’re submitting with that particular date of service the CERT contractor has chosen for a review.”
  • esMD: The electronic submission of medical documentation system (esMD) is another option. With this method, you use the gateway you contracted with and follow standard procedure.
  • Postal Mail: “If it’s a sizeable amount of documentation, or you’ve already saved it to a CD, you can mail it in,” Hanna adds. If you send a CD, it can only contain TIFFs or PDFs and should be encrypted in line with HIPAA Security Rule standards, according to CERT Review contractor AdvanceMed.
  • Email: You may send an encrypted email, but “if [it’s] encrypted, the password and CID# must be provided” with a follow-up phone call or fax, advises AdvanceMed.

Don’t miss: You can make extension requests by telephone only.

Caution: Normally, the CERT contractor grants extensions only in extreme circumstances such as natural disasters like hurricanes, tornadoes, and ongoing fires, according to Hanna.

“But, if you are simply waiting on medical records from the physician, it is possible the CERT contractor may not grant that extension,” Hanna acknowledges. “If that is the case, you should always send the CERT contractor what you have available, and then if they disagree or find something missing or not valid, you do have appeal rights.”

Any claim errors the CERT contractor finds will result in a revised Medicare admittance advice where they will deny that claim and an overpayment demand where they ask you to repay the money, Hanna cautions.

Resource: To read the full CERT document, visit