Can you imagine getting nine out of every 10 established E/M codes wrong -- some downcoded, others denied outright? That's the claim -- no pun intended -- being made by TrailBlazer (the Medicare carrier covering Colorado, New Mexico, Oklahoma, Texas and Virginia) in its most recent medical review findings.
TrailBlazer uncovered average error rates of between 50% and 90% across a total of 200 claims, randomly chosen from multiple practices in all of its covered states (100 from Virginia in particular, with the remaining 100 spread out across the others).
A wide variety of reasons were cited as the cause, but the alleged error rates themselves are so high that several experts have singled TrailBlazer out for being more strict than the average carrier. "I could see maybe 20%, or a little higher. But 90%, I just haven't seen before," says Seth Canterbury, CPC, education specialist for the University of Florida Jacksonville Physicians, Inc.
While the broad category of "documentation errors" was the biggest contributor to errors, within it are a slew of mistakes that run the gamut from no brainers (reason for encounter was to receive lab results, which doesn't count as an E/M) to ones that are very tough to dodge (frequency of E/Ms billed per beneficiary exceeded documented needs for management of stable, chronic conditions).
When I asked TrailBlazer for a breakdown of the 50% and 90% figures, I was eventually told that I must file a Freedom of Information Act (FOIA) request. To give you an idea what kind of answer this is, I am still waiting on a FOIA request I submitted in October of 2008.
Stay tuned for the next issue of Part B News, which features my full story on this established E/M business, with more advice and guidance from Seth and other sources.