Part B Insider (Multispecialty) Coding Alert
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Billing Errors: This MAC's Audit Finds That Some Practices Could Be Collecting More

- Published on Fri, May 01, 2015

Downcoding errors mean that these providers are selling themselves short.

When you hear that a MAC reviewed a practice’s documentation and found errors, you probably assume that the payer uncovered dozens of upcoded charges. But in some cases, the opposite may be also true. That’s the case with a recent CERT audit summary reported by Part B MAC WPS Medicare, which found a variety of errors including several cases where the practices could have billed higher E/M codes.

Downcoding Is Alive and Well

WPS Medicare recently released its Fourth Quarter 2014 CERT Error Summary, which reveals the documentation, coding and billing errors that the contractor uncovered during its most recent audit. Most of the errors were related to insufficient documentation, including situations where the physician signature or order was missing from a claim, as well as missing progress notes and dates of service.

Another 18 percent of errors that WPS found were related to incorrect coding. As you might expect, some of these involved upcodes, such as cases where new patient E/M visits were billed at higher levels than the documentation supported. However, WPS also pointed out several cases where practices actually should have billed higher codes based on the records. Three examples are below:

  • A practice reported 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional…) for a visit with a patient who complained of low back pain and mouth pain. The practitioner subsequently adjusted the patient’s medication during the visit. However, “the documentation reviewed supports an upcode to 99213, with expanded problem focused history, expanded problem focused exam and low complexity medical decision making,” WPS reported. This downcode cost the practice $33.00, the difference in average Medicare reimbursement between 99211 and 99212 in 2015.
  • One Part B practice billed 99212, but the “documentation supports up-code to 99213 with expanded problem focused history, comprehensive exam and straightforward/low MDM,” the payer said. This downcode cost the practice $30.00, the difference in average Medicare reimbursement between 99212 and 99213 in 2015.
  • Another office reported 99213, but the documentation revealed an expanded problem-focused history, detailed exam and moderate complexity MDM, which supported an upcode to 99214, WPS said. This downcode cost the practice $35.00, the difference in average Medicare reimbursement between 99213 and 99214 in 2015.

It’s Not Just About the Money

The number one reason that many practices undercode is because they don’t want to “trigger an audit.” However, coding all low-level E/M codes is sure to get a payer’s attention, because the claims reviewers will be wondering why you never offer high-level evaluations to your patients.

When claims reviewers review “bell curves” to determine whether a practice is coding outside the norm, they aren’t just looking for upcoding--they are looking at trends across the board. This means that a practice with all 99212s and 99213s will be vulnerable, because nearly every practice sees more complex patients requiring high-level E/Ms at least once in a while. If an auditor reviews your records and determines that you’re deliberately downcoding claims, they’ll conclude that you’ve been coding improperly.

You may think that downcoding claims is only costing you a small amount of money per year, but if you’re making the same three mistakes as the practices that WPS audited—just once a week—you’re losing over $5,000.

Best practice: Educate your physicians about how to document thoroughly and select the most accurate code based on that documentation.

Resource: To read WPS Medicare’s CERT results, visit

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