tci Part B Insider - 2005 Issue 2

Downcoding: You Could Be Selling Yourself Short 14.4 Percent Of The Time

For 14.4 percent of claims processed by the carriers, the documentation supported a higher-paying code, according to the Centers for Medicare & Medicaid Services. In fact, not only did the physician perform services that deserved a higher code, but the patient needed a more acute level of treatment. For 2004, CMS arrived at its net estimates of $19.6 billion in overpayments by subtracting the estimated underpayments from the total estimated overpayments. Two E/M codes, 99212 and CPT 99213 , account for 47.1 percent of all undercoded physician claims, CMS says. Only 83 codes out of 9,000...

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