Error rate of 5.3% is below national average compared with other major specialties.
Congratulations, urologists! You are doing a good job of coding, comparatively speaking.
On Nov. 14, 2003, the Centers for Medicare and Medicaid Services announced the national Medicare improper payment rates for 2003. The overall error rate for fiscal year 2003 was estimated at 5.8% (or $11.6 billion), whereas the rate for urologists was 5.3%. CMS audits claims for improper documentation, inadequate documentation, and medically unnecessary medical services.
In the past, Medicare has used a base survey number of 6,000 claims. However, the number of encounters audited this year was expanded to 128,000 claims for the purpose of defining more specifically the type of errors being made. CMS audits not only determined the type of errors that occurred, but also error rates by specific provider type, service type, and contractor processing errors.
The report also listed provider types that had the most errors and those having the lowest error rate. Physician Reimbursement Systems is happy to report that urologists had the lowest error rate of any of the major specialties. The 5.3% error rate for urology was well below the national average. Internists had the highest payroll rate-13.5%-of any of the physician groups.
We should all pat ourselves on the back. Thanks to AUA, PRS, our pharmaceutical supporters, and Urology Times. Together, we have made a difference.
The new informational technology, office automation, and data that are now available will assist us in cutting that error rate even further. Even though urology will probably be scrutinized less than some of the other specialties, it’s not time to relax. Remember, the error rate was for Medicare only and included services we were not paid for as well as those that we were all overpaid.
The error rates are probably much higher in the private sector. CMS wants to reduce the error rate and plans to use the newly gleaned information as a guide. As a result, you will probably see increased carrier activities that promote correct coding and closer scrutiny of the claims submitted. CMS is continuing to work with the contractors that pay Medicare claims and the quality improvement organizations on aggressive efforts to lower the error rate, including:
- improving education and outreach efforts to providers
- making it easier for providers to submit documents
- making it easier for providers to find Medicare rules by adding a section to the Medicare Coverage
CMS will focus on contractors and providers with particularly high error rates.
New Medicare drug payment rules –
The impact of the new Medicare drug payment law on urologists was worse than originally proposed. You are already painfully aware that the payment for goserelin acetate (Zoladex) this year is actually 80% of the average wholesale price, leuprolide acetate depot (Lupron) is 81%, and leuprolide acetate implant (Viadur) is 85%.
Next year, the profits will virtually disappear. The payments will be 106% of the average sales price. The sales price will be determined by the actual information reported by the pharmaceutical companies to CMS as to the average price they sold to all vendors such as physician group purchasing organizations, wholesalers, and retailers.
CMS will re-evaluate the average sales price data quarterly and will adjust the payment for the drugs in each quarter. Also, CMS just recommended that all carriers adopt the “least costly alternative” payment concept currently used by 40 states.
As you are setting up your contracts to purchase these drugs in the future, be sure that your purchase price is no greater than 94% of Medicare’s payment. The price should vary quarterly with payment changes. There should be a 6% spread. However, volume purchasers may not be able to increase that spread by very much.
There is good news. CMS has increased the payment, or at least provided a temporary bonus, for chemotherapeutic injections (96400). Code 96400 will pay about $63, depending on location, for the next 2 years. If your carrier requires the use of therapeutic injection codes and does not allow you to use the chemotherapeutic injection codes, let us hear from you. We should get that changed.
The regulations specifically state that you cannot charge a 99211 on the same date as the injection, even if the nurse provides a significant and separate medically necessary service. However, if the physician sees the patient and provides a significant, separate, and medically necessary service, he or she should charge for the E&M service provided. Obviously, the physician will have provided a higher level of service than a 99211.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
