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?

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