If the latest Medicare report is any indication, outpatient surgery claims could use some TLC in 2008. According to CMS's Comprehensive Error Rate Testing (CERT) results, Medicare carriers discovered more than $259 million in undercoding billing errors and $1.6 billion worth of claims that were paid, but later found to have no supporting documentation, meaning that those dollars had to be paid back.

If you don't want to be part of the billions of dollars in errors that Medicare receives in 2008, you'll benefit by studying the most common errors that ASCs and hospitals submitted to Medicare last year and knowing how to reverse any bad coding habits.

5 of the biggest ASC coding errors
Freestanding ambulatory surgery centers boasted very low error rates, according to the CERT report, with only 0.2 percent of their claims paid in error. But these errors still resulted in almost $800,000 in improper payments from errors such as these.

1. Ob-gyn services. When CMS ranked the error rates by specialty, ob-gyns came in the second highest (after general practitioners) with a whopping 23.6 percent error rate. The report didn't say which services were most error-prone, but ASCs frequently miscode breast aspirations. During fine needle aspiration, the physician uses a fine-gauge needle and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. Report these procedures using 10021 or 10022. But if the doctor performs a puncture aspiration, report 19000.

2. Cardiologists. They had a 4.6 percent error rate, according to the CERT report, with more than $292 million in improperly paid claims. Cardiologists perform a variety of services in the ASC setting. A common error occurs when coders can't determine which codes to report and which are bundled into the main service. For example, the cardiologist might document removal of atrial and ventricular pacemaker leads, removal of pulse generator, debridement of infected pocket and removal of necrotic tissue, closure of facial layers and a Jackson-Pratt drain place via trocar. However, all of these services bundle into just two codes. You'll report 33233 for the pacemaker pulse generator removal, and 33235 for removing the dual-lead electrode system.

3. Failure to use type of bill 13X. Any ASC claims that are subject to the Outpatient Prospective Payment System (OPPS) should be billed on the TOB (type of bill) 13X. ASC billers frequently failed to identify which services belonged on the 13X TOB last year, because that error resulted in $23.5 million in improper claim payments.

4. Outpatient E/M codes. A big source of errors noted in the CERT report was incorrectly coding outpatient E/M (evaluation and management) services. The combination of codes 99213 and 99214 alone cost Medicare more than $375 million in improper payments. The report doesn't outline the specific errors that caused these high improper payment rates, but one error that ASC physicians have made in the past is the attempt to "unbundle" an E/M code from a surgery.

Because surgical procedures all include "global surgical periods," which vary according to the information outlined on Medicare's Physician Fee Schedule, you can't separately report an E/M service on the same day of the surgery (or the day before), unless that E/M service is what caused the decision for surgery. However, in the vast majority of cases, surgeries performed in ASCs have usually been pre-scheduled, and you therefore shouldn't report any E/M service along with the surgical procedure. In addition, the outpatient E/M codes aren't on the ASC's approved list for 2008.

5. Gastroenterology services. The CERT report indicates that gastroenterologists had an 8.4 percent error rate based on the claims they submitted to Medicare. Coding experts say that one common gastroenterology error occurs when ASCs code procedures involving tube insertion, removal and replacement. CPT added nine new codes for these services that went into effect on Jan. 1, 2008. If the physician replaces a gastrostomy tube, you'll report 43760 (change of gastrostomy tube) this year. Keep in mind that you should continue to report 43246 for your percutaneous endoscopic gastrostomy (PEG) tube placements. You'll use code 43235 (upper gastrointestinal endoscopy) when the physician changes (replaces) the tube under fluoroscopic guidance.

5 of the biggest hospital billing errors
If you perform most of your services in the hospital setting, chances are you've reported one of the services below. CMS has identified these procedures as being among the most commonly reported in error, so ensure that you're billing these services properly in the coming year.

1. Subsequent hospital care. If you're seeking an area where you can easily make a change, look no further than subsequent hospital care. These services racked up half a billion dollars in improper payments, with 99232 and 99233 flagged as "problematic codes," according to CMS.

In addition to being flagged as one of the most improperly coded services, subsequent hospital care code 99232 was also identified as one of the services most often reported but lacking documentation. This code only had a 1.6 percent error rate, but because it was reported so frequently, these errors caused physicians to collect nearly $41 million more in Medicare payments than they were entitled to.

When a claim is flagged as a "no documentation error," that means the physician couldn't produce any documentation to support the claims that he reported. "An unusual number of the claims sampled in Florida resulted in no documentation errors during the November report period," says the CERT report. The sky-high "no documentation" error rate in Florida accounted for 63.5 percent of the national "no documentation" error rate.

It's not enough to dictate "seen and agree," "follow up in three months," "refer to specialist," "continue present medication and therapy," "patient comfortable" or any of the standard all-encompassing notes in the patient's chart. Instead, the physician should document the entire subsequent hospital visit, including notation of the history, medical decision-making and exam, as well as the diagnoses that the patient experienced.

2. Inpatient consultations. Consultation errors are commonly flagged as a major source of inappropriate coding and billing, and the CERT report bore that out as well.

Inpatient consultation code 99255 was a common source of insufficient documentation errors, with a 5.9 percent error rate. The report notes, "A carrier paid $139.69 for an inpatient consultation. Multiple attempts were made to obtain the documentation. Documentation received consisted of multiple copies of the discharge summary only. As a result, the CERT contractor counted the claim line in error and recouped the entire amount."

How can you avoid having to reimburse the hundreds that you've collected for inpatient consults? Your documentation, as always, is going to be the main support source for your claims.

First, ensure that the consult request is in the requesting physician's chart before the physician performs the consultation. If you're serving as the consulting physician, make sure you do your part by writing a report of your findings and recording it in the patient's medical record.

3. Emergency department visits. Emergency department (ED) visits were designated as a huge source of underpayment coding errors, and last year, physicians left $4.4 million on the table by undercoding 99283. If you want to collect all the reimbursement you deserve in 2008, make sure your ED claims are pristine.

First, keep in mind that any physician can report the ED codes (99281-99285) for an ED service, as long as the visit meets the ED code criteria. An ED, as defined by the Medicare Internet Only Manual (IOM, Publication 100-4, Chapter 12, Section 30.6.11B), is "an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention." CPT defines an ED similarly as "an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention."

In addition, you can report 99281-99285 even for non-emergency services provided in the ED. "The only requirement for using the emergency department codes is that the patient be seen in the emergency department for an unanticipated service," says the IOM.

4. Initial hospital visits. CMS found that initial hospital visit code 99223 was upcoded in 13 percent of the claims reviewed, which means that physicians reported 99223 but their documentation supported a lower code.

You should select the appropriate-level of initial hospital care using the key E/M criteria of history, exam and medical decision-making (MDM). You must meet all three requirements to report a given service level, so if the physician documents a comprehensive history and exam, and MDM of moderate complexity, he only qualifies for code 99222.

5. Imaging procedures. CMS pinpointed imaging services as one of the top 20 services with the highest improper payments. With a 4.9 percent error rate, improper payments for these services nearly hit $18 million last year.

Medicare didn't specify the most frequent imaging errors that prompted the inappropriate payments, but coding experts say that one common source of radiology errors is missing documentation of a physician's order for the radiology service. In most cases, radiology procedures require a physician's order, so any facility performing these services should ensure that when required, an order is in the patient's file.