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Welcome to the Swiftaudit blog, we’re glad you’re here! We’ve designed this page with you in mind, and we hope you’ll find our articles both useful and encouraging. We’ll share tips from our experts on how to work smarter, code and audit better, and how to find the coding job that makes you happy!

We’re all in this talented community of auditors together, and we look forward to getting to know you better. So sit back, scroll down and enjoy!

2022 ICD-10-CM Guidelines By Chapter

The official 2022 ICD-10-CM Guidelines are now available and active! This updated code set is to be used for discharges and patient encounters occurring from October 1, 2021 through September 30, 2022. It’s time to get familiar with what’s new and what has changed.

To help provide a quick reference, we have split the original 115 page document into separate Chapters, each approximately 2-5 pages long and with a focus on specific code groups. By referencing our Chapter list you can more efficiently focus on the specialty you are coding, auditing or teaching.

Be sure to review Section 1.B. General Coding Guidelines for the latest ICD-10-CM general coding guidance.

See what has changed for ICD-10-CM in 2022 in the Tabular Addenda (42 pages).

FY 2022 ICD-10-CM Guidelines (as of July 2022)

Section 1.A: Code Conventions

Section 1.B: General Coding Guidelines

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9

Chapter 2: Neoplasms (C00-D49)

Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) — Reserved for future guideline expansion

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

Chapter 6: Diseases of the Nervous System (G00-G99)

Chapter 7: Diseases of the Eye and Adnexa (H00-H59)

Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) — Reserved for future guideline expansion

Chapter 9: Diseases of the Circulatory System (I00-I99)

Chapter 10: Diseases of the Respiratory System (J00-J99), U07.0

Chapter 11: Diseases of the Digestive System (K00-K95) — Reserved for future guideline expansion

Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)

Chapter 14: Diseases of Genitourinary System (N00-N99)

Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)

Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)

Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

Chapter 20: External Causes of Morbidity (V00-Y99)

Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

Chapter 22: Codes for Special Purposes (U00-U85)

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Is CMS / HHS really checking for undercoding?

Yes. They are!

The 2018 Medicare Fee-for-Service Supplemental Improper Payment Data identifies undercoding in their audit findings.

CMS reported 1.93 billion dollars in underpayments in 2018.

1.93 billion dollars equates to about $4,800 per active MD in the United States per year who typically bill E/M codes. There are 620,520 active MD’s per the AMA Physician Masterfile (December 2019). 36% are in specialties as anesthesiology, pathology, psychiatry, and radiology using other CPT(R)/ HCPCS codes.

CMS reported that Office Visit E/M codes 99213, 99212, Initial Hospital E/M code 99222, and Emergency services E/M code 99283 are among the top 8 codes being reported as undercoded / underpaid.

What about commercial payers?

You can google to see the number of lawsuits and filings against commercial payers for underpayment. The American Bar Association has a “healthy” pool of newsletters focused on health law and payment disputes. Many of these disputes against commercial payers are about underpayment, not overpayment.

Many RCM consultants will tell you that it’s good business policy to track payments from your payers. If your underpayments from your commercial payers is significant, having a base of proper coding can strengthen your case for dispute and/or negotiations. Your coding pattern is collected and trended by all of your payers – whether Medicare or commercial payers. They know your coding pattern, do you?

What is your percentage of undercoding?

What is the impact of undercoding on your practice’s revenue?

Are you describing your practice’s risk burden properly, so you can best serve your patients?

Internal Audits-Undercoding is a good strategy, right ?

Overcoding is an obvious audit finding. Most internal and external audits are focused on overcoding as a high risk topic. The risks are typically listed as submitting a “False Claim,” potentially being flagged as an audit candidate, being charged for overpayments, and being an “outlier.”

Due to these often touted compliance concerns, many practices choose a strategy of undercoding.

Is undercoding a good strategy to stay  “under the radar”?

Noviatas, a CMS Medicare contractor responsible for providers in AR, CO, DC, DE, MD, LA, MS, NJ, NM, OK, PA, TX, Indian Health & Veteran Affairs sees undercoding as “aberrant.”

CERT is a measure of improper payments. The goal of CMS and Novitas is to pay claims that meet Medicare’s requirements and pay them at the proper level of service. When there is an underpayment due to under coding, we did not pay the claim correctly and it is counted as an improper payment error. You are reimbursed for the higher level of service. Under coding misrepresents the true level of care provided to Medicare beneficiaries.

Under coding errors can statistically impact calculated error rates in the tens of millions of dollars. These statistics are used to calculate future Medicare payments and track trends in healthcare delivery. Patterns of under coding may be viewed as aberrant and open your practice up to audits and reviews. In addition, under coding impacts your practice revenue. You are not being appropriately paid for the level of service you provide to your patients. Correcting under coded claims can mean costly appeals.

Auditors at Healthcare Compliance Network (HCN) an healthcare compliance and RCM firm provides this perspective.

… the golden rule of coding is, and always will be, to code to the highest specificity. The payers don’t want you to lowball – they want the most accurate code which reflects the service performed. Without that, they cannot effectively rate policies, understand the risk burden, accurately set premiums, etc.

An undercoding error is still an error, and it will be graded as such in the event of an audit. That’s important because an unacceptable error rate will keep you on the radar, even if it’s due to undercoding.

Plus, it’s worth reiterating the adage that too much of anything is bad. Audits are often triggered by aberrant billing distribution patterns by CPT code. If you submit an abnormal number of claims with lower-level codes it is, in effect, no better than generating an abnormal volume of high-level codes. It implies that something is not right because you are outside the norm.

What is your percentage of undercoding?

What is the impact of undercoding on your practice’s revenue?

Are you describing your practice’s risk burden properly, so you can best serve your patients?

Internal Audits – Financial Impact

In our last post, we reviewed the importance of an internal audit plan. Now let’s look at how that might impact your financials.

Evaluation and Management (E/M) services have been a high priority audit topic for all payers for a long time. In 1995, we released E&M Coder as an audit and education tool. In 2010, E/M services accounted for almost 30% of all Part B payments, equating to $32.3 billion. [We can give at least $100 to everyone in the USA every year for E/M services paid just by Medicare.]

In a study by the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) in 2010, they found $6.7 billion of inappropriately paid claims, representing 21% paid for E/M services that year.

Of the total $32.3 billion paid for E/M services in 2010, 42% of claims were incorrectly coded. They were either higher (upcoded) or lower (downcoded) than they should have been. 19% of claims had insufficient documentation for the E/M services billed.

Though this Study is over 10 years old, what if

  • 42% of your billing was improperly coded?
    • 21% over coded – what is your risk?
    • 21% under coded – what revenue opportunity was lost?

What if

  • 20% of your billing was improperly coded?
    • 10% over coded – what is your risk?
    • 10% under coded – what revenue opportunity was lost?

How much would these error rates cost your practice?

In the December 2020 MGMA Survey, those who reported their denials were due to documentation / coding issues noted the following as the top reason for their denials:

https://www.mgma.com/data/data-stories/finding-hidden-treasure-by-uncovering-and-fixing

Coding issues (including wrong modifier and improper bundling of CPT® codes) — 23%

Medical necessity requirements — 14%

Missing information/documentation — 11%

Do you know what your top reasons for denials or underpayment are?

How confident are you with your provider’s 2021 E/M coding?

If you use internal staff to code and/or audit, when was the last time you had an external review done?

Image credit: graphicstock

Internal Audits

Why is an internal audit plan essential for healthcare practices?

An article by the AMA “13 reasons your practice should have a medical record audit” quotes Deborah J. Grider as saying that an audit “is a preventive measure if done at least once a year.”

What does an audit prevent?

One key risk is governmental investigational auditors.

On CMS’ Recovery Audit Program webpage, it states: “CMS often receives referrals of potential improper payments from the MACs, UPICs, and Federal investigative agencies (e.g., OIG, DOJ).”

As a sample, here are the Approved Recovery Audit Topics required of all Medicare health care insurers (MAC) related to evaluation and management services.

In the 2018 AMA article Avoid these missteps to slash your medical coding audit risk, the author writes:

The OIG also warns against billing for services:

  • You did not actually render.
  • Were not medically necessary.
  • Were performed by an improperly supervised or unqualified employee.
  • Were performed by an employee who has been excluded from participation in the federal health care programs.
  • That were of such low quality that they are virtually worthless.
  • That were already included in the global fee, such as billing for an E/M service the day after surgery.

What about private insurers?

As of 2019, Blue Cross states: “Blue Cross follows the Centers for Medicare & Medicaid Services (CMS) 1995/1997 and CPT E/M selection guides for these services.” Most private insurers follow the policies and guidelines published by CMS and the AMA.

An internal audit plan is essential to ensure that your practice stays healthy.

There are many firms that offer compliance services. Compliance is often the topic of conferences, webinars, in-services, and articles. As a result, many practices have a compliance plan.

The operational questions are:

When was the last time you reviewed your compliance plan?

What topics in the compliance plan are not being followed?