Infectious diseases (ID) specialists had the second-highest rate of improper coding for Medicare fee-for-service payments in the latest semi-annual error rate report from the Centers for Medicare and Medicaid Services (CMS)—a fact that may subject you to increased scrutiny as CMS expands its auditing program.

In the May 2008 Improper Medicare Fee-for-Service Payments (IMPF) Report, 16.4 percent of claims that Medicare paid to infectious diseases physicians contained an error. Nearly 45 percent of these errors were because documentation was lacking or insufficient.

IDSA strongly encourages members and their staffs to submit all requested documentation in a timely manner. If you fail to do so, you may soon be more likely to find an auditor on your doorstep. CMS is setting up a nationwide auditing system to recover funds overpaid to providers and expects to have the system running by 2010. (Information on what to do in the event of an audit is available in the Billing and Coding section of the IDSA website. You must log in to access this page.)

The majority of ID physicians’ errors (55.4 percent) were due to what CMS considered incorrect coding. In most cases, CMS and the physician differed by only one coding level. Coding evaluation and management (E&M) services is an inherently subjective process—especially in the E&M families with 5 code levels—and IDSA has previously asked CMS not to include one-level coding differences in its error rate calculations.

Key Points to Remember in Determining the Appropriate Level E&M Code

• Understand the documentation requirements: Some E&M code families require all three key elements, and others require only two of three key elements.
• High-level initial patient visits do not always lead to high-level subsequent-patient visits. Changes in a patient’s condition between visits should be reflected in the code levels chosen.
• If a patient is non-responsive or uncommunicative, you should document “unable to execute review of systems and history” in the patient’s chart.
• In order to bill critical care codes, you must document at least 30 minutes of floor/unit time that meets criteria for critical care. Providing care in an ICU setting is not in and of itself justification for billing a critical care code.

Please go to www.idsociety.org/correctcoding.htm for more information on how to avoid coding errors, including ID-specific correct coding resources.

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