Improving Your Quality and Education Program

The Centers for Medicare & Medicaid Services (CMS) measure the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Towards the end of each year, CMS publishes detailed improper payment rate information breaking down the percentages, types of errors, service lines, CPT codes, providers, and so on.

The 2019 Medicare Fee-for-Service Supplemental Improper Payment Data disclosed astonishing error rates for evaluation and management services. Part B claims measured during the July 1, 2017, through June 30, 2018 reporting period revealed an 8.64% improper payment rate for a total of $8.66 billion paid in improper payments. The leaders of the pack include:

E & M Codes Projected Improper Payments Improper Payment Rate 95% Confidence Interval No Doc Insufficient Doc Medical Necessity Incorrect Coding Others % of Overall Improper Payments
Initial Hospital Care(99223) $433,929,403 24.1% 21.9%-26.2% 2.5% 17.6% 0.0% 79.9% 0.0% 1.5%
Office/Outpatient Visit(99214) $423,978,684 5.0% 3.4%-6.5% 4.8% 28.4% 0.0% 66.8% 0.0% 1.4%
Office/Outpatient Visit(99213) $366,646,442 6.9% 4.6%-9.1% 0.0% 18.6% 0.0% 81.4% 0.0% 1.2%
Subsequent Hospital Care(992133) $342,328,321 18.1% 16.0%-20.2% 8.4% 21.0% 0.0% 70.6% 0.0% 1.2%
All Codes with Less Than 30 Claims $243,600,135 31.7% 22.7%-40.7% 6.5% 85.4% 3.0% 4.2% 0.9% 0.8%
Emergency Dept Visit(99285) $228,420,881 13.8% 11.5%-16.1% 4.9% 6.9% 0.0% 88.3% 0.0% 0.8%
Office/Outpatient Visit New(99204) $203,913,495 15.3% 12.7%-17.8% 0.0% 6.4% 0.0% 91.4% 2.1% 0.7%
Critical Care First Hour(99291) $175,081,314 18.3% 13.1%-23.5% 3.4% 38.8% 0.0% 57.8% 0.0% 0.6%
Subsequent Hospital Care(99232) $162,528,824 5.7% 3.1%-8.3% 30.0% 46.8% 0.0% 23.2% 0.0% 0.5%
Initial Hospital Care(99222) $119,915,092 16.1% 11.7%-20.5% 0.0% 22.2% 0.0% 77.8% 0.0% 0.4%
Office/Outpatient Visit est(99215) $108,347,080 9.9% 7.6%-12.1% 4.4% 0.1% 0.0% 95.5% 0.0% 0.4%
Hospital Discharge Day(99239) $107,795,571 22.6% 17.8%-27.3% 1.5% 31.7% 0.0% 61.4% 0.0% 0.4%
Office/Outpatient Visit new(99205) $93,515,232 18.8% 13.9%-23.6% 0.0% 11.3% 0.0% 88.7% 0.0% 0.3%

Code accuracy has always been a priority, but the incorrect coding percentages above suggest that we have some work to do. It’s well known that utilization for diagnosis and procedure codes has evolved over the past several years, and they are no longer used for disease classification and reimbursement alone. Codes are reported, analyzed and used to make decisions in areas such as:

  • Reimbursement
  • Disease classification
  • Center for Disease Control (CDC) and other external reporting
  • Population health
  • Public data reporting
  • Quality and patient safety measures
  • Research
  • Administrative uses

As an industry we have so much riding on the reliability of our coded data that we must be certain coders receive the education necessary to successfully achieve 95% or greater accuracy rates. Annual code updates and guidelines changes are just two factors that prove that we cannot be successful without ongoing, continuous education. Medical coders independently seek training to comply with credential maintenance requirements, advancements in medical technology and annual code changes, but we are seeing signs that these efforts alone are not providing medical coders with the support they need to successfully meet quality obligations.  In effort to improve code accuracy and eliminate organizational risk, leaders must act now. Follow the below steps to jump start your training and education programs:

  1. Baseline assessment- If you don’t already have a baseline audit on your coding team, now is the time. Determine the sample size that you feel will be a good representation and roll it out across the team. Be transparent. Talk to your team about the baseline assessment and accuracy requirements. Stand firm. Don’t budge on the 95% accuracy rate. There will most likely me some coders that will not meet the 95% requirement on that first review and that’s okay. Take what you learned from the baseline to better understand areas of opportunity within your coding team and build on it. Create education and educate. Track your progress and be diligent.
  2. Ongoing quality reviews- Coders that meet the 95% accuracy rate are ready to be placed in a “steady state” review process. Develop a quality review calendar and stick with it. The information gained from these reviews is valuable data. Quality assessments help you understand where your challenges are; what education is needed and if you have any coders that may be struggling. Assess and educate. Every error, regardless of overall score requires education.
  3. Education- Education is the foundation of your business. You will get out of it what you put into it. When you invest in your people, you are investing in your business. New procedures are released on a yearly basis. Teach your medical coders to code each new service, don’t expect them to learn on their own. Add new procedure to your audit schedule and assess until you are confident that your coders are accurate in their code assignment. Educate on new code changes, coding clinic updates and guidelines changes before they are implemented.
  4. Standardize policies and procedures- Review your current policies and procedures and ask yourself the following questions: Are they current? Do they provide coders with clear direction? Do all coders have access to them? If you answered “no” to any of these questions, revise your policies. Educate your team on all changes and where each policy can be found.
  5. Don’t be afraid to partner: If you are short on resources and don’t have the bandwidth to perform the necessary quality reviews or provide educate your team, you may benefit from partnering with a medical coding company. Partnering with a coding company that offers medical coding, auditing and coder education can provide you with the support you need to get your coding accuracy to best practice standards.
  • Posted by admin
  • On April 22, 2020
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