Like many Medicare contractors, Palmetto GBA uses results from the Comprehensive Error Rate Testing (CERT) program to monitor the accuracy of submitted claims. In the most recent accuracy report, dated November 2007, the code group with the highest error rate for Palmetto GBA is consultations (both inpatient and outpatient). The primary reason for these errors is that medical documentation did not support the level of service submitted.
Facts:
- The 'paid claims error rate' for consultations is 21.5 percent. This means that more than one in every five consultation claims selected for review under this program is coded incorrectly.
- The paid claims error rate is calculated based on the error percentage among claims selected for review as part of the CERT program. When this error rate is applied to all consultations submitted to Palmetto GBA, the projected dollars paid in error (mostly due to 'upcoding') exceed $38 million for claims submitted during the twelve-month period from April 2006 through March 2007.
- Consultation errors cross many specialties
- Although accuracy errors have continued to decline for Palmetto GBA, the number of errors for consultations remains consistently high
- Palmetto GBA's primary goal is to ensure that you have the knowledge, tools, and resources you need to submit accurate claims
Tips for Correct Coding:
- All consultations require documentation of the level of history, physical examination, and medical decision making. These are the key components of Evaluation and Management (E/M) services, including consultations.
- For all consultations submitted to Medicare, documentation in the patient's medical record must meet or exceed the level of service for all three of these three key components, as specified in Current Procedural Terminology (CPT). If any one of the three key components is not documented at the specified level, select the CPT code that encompasses the lower level of service.
- Documentation in the patient's medical record for consultations must also include a documented request from the referring physician for opinion or advice, evidence of the opinion rendered by the consulting physician, and a written report from the consulting physician to the referring physician or health care practitioner
What You Can Do:
- We encourage you to conduct self-audits on claims submitted to Palmetto GBA. You may use any one of a number of privately developed 'scoring' tools or Palmetto GBA's E/M Score Sheet (available on our Web site).
- Ensure that new staff in your office understands the E/M Documentation Guidelines. Palmetto GBA offers periodic workshops designed to familiarize office staff and clinicians with these guidelines.
If you submit claims to Palmetto GBA for consultations, we may contact you to ensure that you understand the documentation guidelines associated with these services. Again, it is important to note that our goal is to assist you in filing accurate claims. We look forward to continuing our ongoing dialogue with you.
References:
- E/M Documentation Guidelines, developed by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA): www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
- The Palmetto GBA E/M Help Center includes E/M 'frequently asked questions,' educational resource materials, and the Palmetto GBA E/M Score Sheet. The E/M Help Center is located under 'Browse by Topic' on the Ohio and West Virginia home pages:
- For a schedule of upcoming Palmetto GBA E/M workshops, refer to our Education Web pages, under 'workshops':
- Read more about the CERT program on the CMS Web site: www.cms.hhs.gov/cert
last updated on 03/04/2008