Improper Payment Report Shows Downcoding PrevalenceNo. 1 on the top 20 list of types of services with downcoding errors is (drum roll, please)… established office visits, according to the U.S. Department of Health & Human Services (HHS) Supplementary Appendices for Medicare Fee-for-Service (FFS) 2015 Improper Payment Report.

Under the direction of the Centers for Medicare & Medicaid Services (CMS), the Comprehensive Error Rate Testing (CERT) program measures improper payments in the Medicare FFS program. The improper payment rate is calculated from a sample considered to reflect all claims processed by the Medicare FFS program during the report period.

Improper payments do not necessarily imply fraudulent claims — the CERT program cannot label a claim fraudulent, according to CMS. If you are a victim or perpetrator of an improper payment, you simply did not comply with Medicare requirements.

Improper payments, when detected, must be corrected. You can believe CMS won’t stop until it recoups overpayments it makes to physicians. But who’s watching out for the physicians who overpay Medicare?

Oh, it happens. In fact, according to the report, the improper payment rate for established office visits in 2015 was 1.4 percent, for a projected $209,377,169 in improper payments.

In the report, of the 1,304 claim lines reviewed for CPT® 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity, 658 lines were questioned, for an error rate of 50.5 percent.

Downcoding a Real Concern

John Verhovshek, CPC, writes in his article Downcoding Is as Bad as Upcoding, that “Coders and providers (rightly) worry about upcoming, or coding at a ‘higher level’ than supported by documentation or medical necessity; however, ‘downcoding,’ or coding at a level lower than the level or service supported by documentation or medical necessity, is equally damaging, from a compliance perspective.”

The National Correct Coding Initiative (NCCI) General Correct Coding Policies, Chapter 1, states:

If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code.

Tips for Avoiding Downcoding

Downcoding is usually the result of insufficient documentation. In the article Responding to a Payer Audit, Ellen Risotti-Hinkle, BS, CPC, CPC-I, CPMA, CEMC, CIMC, CFPC, writes, “Office visit notes alone are often insufficient to reflect the complexity of a patient’s medical history and the physician’s medical decision-making. Because these are key components to determine the appropriate E/M level, lack of sufficient documentation may result in the auditor downcoding or disallowing the level of service billed.” The same holds true for the medical coder. Every Certified Professional Coder (CPC®) knows the adage, “If it isn’t documented, it wasn’t done.”

Bottom line: When coding for established patient visits, consider all the evidence. Did the physician review the patient’s past, family, and social histories? Look for lab test results, X-ray reports or other diagnostic services relevant to the service, any orders for these services, referrals, consultation reports, etc. To substantiate the service level billed, copy this information and submit it with the claim.