Primary care troubled by coding errors

Medicare officials suggest doctors may have trouble deciphering evaluation and management guidelines in billing.

By Markian Hawryluk, AMNews staff. Dec. 8, 2003.

Washington -- New data on the percentage of Medicare claims submitted and paid improperly show primary care physicians and carriers are struggling with the complexity of coding and billing regulations, physician groups said.

In November, the Centers for Medicare & Medicaid Services announced a national error rate for fiscal year 2003 of 5.8%, representing about $11.6 billion in Medicare spending. The Health and Human Services Office of Inspector General, which had conducted the review in past years, reported an improper payment rate of 6.3% in 2001 and 2002.

While the error rate is often cited as a measure of fraud in the program, it is intended to quantify the percentage of claims not paid properly under Medicare billing rules. Those include services that were legitimately provided but improperly billed. It also includes such mistakes as using the wrong code or not providing sufficient documentation to show that a service was medically necessary.

For the first time, the survey calculated specialty-specific error rates. CMS now plans to focus its corrective efforts on those categories or types of health care practitioners with high percentages of improper claims.

The physician specialties with the highest rates include many of the primary care specialties that tend to bill more for evaluation and management services than for other procedures. Internists, general physicians and family physicians had error rates of 20% or higher for submitted claims, while Medicare carrier error rates for reimbursement to those specialties were 16% or higher.