The 2018 Medicare Fee-for-Service (FFS) Improper Payment Report
The most recent Comprehensive Error Rate Testing (CERT) report outlines common payment errors for physicians and hospitals in 2018 as well as provides a roadmap for expected future payment errors. Improper Medicare FFS payments in 2018 have been estimated in excess of $31 Billion which is more than 8% of the total payments made.
Overall, the payment errors are attributed to several categories.
Category | Percent of Errors |
Insufficient Documentation | 58.0% |
Medical Necessity | 21.3% |
Incorrect Coding | 11.9% |
Other | 6.3% |
No Documentation | 2.6% |
The report includes projections for future payment errors for hospitals and physicians and identifies specific DRGs and CPT codes associated with high payment error rates. The report also highlights errors related to up-coding, missing orders, certifications, and diagnostic test results, as well as inconsistent medical record documentation.
Highest Improper Payments: Part A Hospital
DRG | Description | Improper Payment Rate |
947, 948 | Signs & Symptoms | 32.00% |
313 | Chest pain | 28.30% |
515, 516, 517 | Other Musculoskeletal System & Connective Tissue O.R. Procedure | 22.40% |
312 | Syncope & Collapse | 17.80% |
884 | Organic Disturbances & Mental Retardation | 16.90% |
056, 057 | Degenerative Nervous System Disorder | 16.40% |
266, 267 | Endovascular Cardiac Valve Replacement | 16.20% |
885 | Psychoses | 13.20% |
100, 101 | Seizures | 12.90% |
637, 638, 639 | Diabetes | 10.60% |
Highest Improper Payments: Part B Evaluation & Management
CPT | Description | Improper Payment Rate |
99234 | Observ/Hosp Same Date | 65.6% |
99490 | Chronic Care Management | 63.5% |
99220 | Initial Observation | 40.2% |
99306 | Nursing Facility Care, Initial | 36.5% |
99292 | Critical Care, Each addl 30 min | 35.7% |
99212 | Office Outpatient Visit | 30.6% |
99310 | Nursing Facility Care, Subsequent | 30.0% |
99211 | Office Outpatient Visit | 29.3% |
99223 | Initial Hospital Care | 27.2% |
99231 | Subsequent Hospital Care | 21.6% |
Accurate and timely identification of provider and organizational risks is a critical component of any effective compliance program. We recommend you review the complete CERT report and conduct proactive auditing and monitoring of known risks that are applicable to your organization. The HBE team is available to provide you with assistance to identify your risk areas and conduct auditing and provider education as needed.
The complete CERT report can be located at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports-Items/2018MedicareFFSSupplementalImproperPaymentData.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending