ED Coding & Reimbursement Alert - 2015 Issue 2
Compliance: CMS: Initial Hospital Visit Claims Riddled With Errors
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Article Overview
This article summarizes CMS Comprehensive Error Rate Testing findings and highlights where Medicare Part B claims were most often paid in error. It is aimed at coders, auditors, and billing staff who want to understand the broad categories of documentation and claim-submission issues CMS identified across inpatient visits, office E/M services, musculoskeletal procedures, chiropractic care, and major joint surgery. The article also references CMS guidance and reporting materials relevant to compliance review and internal education.
Why This Topic Matters
It helps practices recognize the service categories CMS is scrutinizing so they can evaluate whether their documentation and coding processes need review. The article is especially relevant for teams responsible for compliance, audit response, and physician education.
Article Sections
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Documentation Sorely Lacking
Introduces the CERT findings, overall error rates, and the specialties and service areas with elevated claim error rates.
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Avoid These Common Mistakes
Summarizes the article’s main compliance concerns and transitions into the service categories discussed in the report.
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Inpatient Hospital Visits
Covers CMS findings related to inpatient hospital visit claims and the documentation issues associated with this service category.
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Minor Musculoskeletal Procedures
Discusses minor musculoskeletal procedure claims and the documentation concerns CMS identified for this group.
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Chiropractic Visits
Reviews CMS findings for chiropractic services and the documentation themes tied to those claims.
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Major Joint Replacements
Addresses major joint replacement claims, related documentation concerns, and CMS guidance referenced by the article.
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Subsequent Hospital Visits
Summarizes the issues CMS identified for subsequent hospital visit claims and the suggested internal review approach.
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Hip Replacements
Highlights hip replacement surgery coding complexity and the range of related procedures discussed in the article.
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E/M Visits Among ‘Problem Codes’
Identifies selected evaluation and management services and diagnosis groups that CMS flagged as problem areas.
What You Will Learn
- How CMS CERT reporting is used to spotlight Medicare Part B claim errors
- Which broad service categories were highlighted for elevated error rates
- What documentation themes are emphasized for inpatient, procedural, and chiropractic claims
- How the article frames internal review and education as compliance responses
- Which evaluation and management and diagnosis categories CMS flagged as problem areas
Who Should Read This
- Medical coders
- Billing staff
- Compliance auditors
- Practice managers
- Physician educators
- Revenue cycle teams
Codes Discussed
Code Ranges Discussed
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