Health Information Management

News: E/M services remain a leading cause of improper Medicare payments

CDI Strategies, April 21, 2016

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Evaluation and management (E/M) services payments—the principal payment method for physicians—resulted in a projected $4.5 billion in improper Medicare payments in 2014, accounting for 9.3% of the overall improper payment rate for Medicare fee-for-services, according to the April 2016 Medicare Quarterly Compliance Newsletter.

CMS’ Comprehensive Error Rate Testing (CERT) program, looked specifically at observation services and found that most improper payments were due to insufficient documentation such as a lack of physician order, physician signature, or progress notes.
For example, an internal medicine specialist’s bill lacked signed and dated physician orders for observation services, was missing a signed and dated progress note for the face-to-face encounter on the date of service, and although the submitted documentation included a discharge summary, it did not include documentation of a visit with the patient.
The CERT reviewer requested the documentation, but only received a history and physical from the day before the observation date of service, signed by a different physician. The claim was scored as having insufficient documentation and the Medicare Administrative Contractor recovered the payment.
Editor’s note: This article was adapted from the original published in JustCoding.


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