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By: Tomás Hernández Del Toro, Esq.
In the year 2023, the Service Centers of Medicare and Medicaid (CMS English) identified several common billing errors that affected healthcare providers throughout the United States and Puerto Rico. These errors not only have financial implications, but also can affect the quality-of-care patients receive. Let’s explore the five most common billing errors identified in 2023 and some examples that are usually associated with these errors.
Specific code example – ICD-10-CM Z01.419 (Consultation for observation and evaluation of newborn for suspicion of disease or condition) This code is incorrectly used in billing claims for adult patients, resulting in an inaccurate payment by CMS.
It is important to mention that this type of error can result in significant fines and legal sanctions for the suppliers involved, including refunds, exclusions from federal health programs, and potential lawsuits for fraud.
CPT code 99214 was not properly used (Moderate severity level Consultation) in billing claims, since the necessary documentation to justify this level of service was not present in the clinical records.
Example of specific code – CPT 99203 (Low Severity level Consultation). There were cases in which this code was used inappropriately to describe consultations that, according to the clinical documentation, should have been billed using higher severity level codes.
Claims were found for patients who did not meet the requirements for a visit, resulting in incorrect compensation by CMS.
We can conclude that the identification and correction of these billing errors is essential to maintain integrity and transparency in the health care system. CMS projections on the improper payment of 2023 claims are estimated at 7.46% of “Fee-for-Services” (FFS) claims. This is estimated to be a loss of more than 30 billion dollars. Although it is not possible to provide specific fines and penalties in 2023, it is crucial that suppliers are aware of the financial and legal implications associated with billing errors. By understanding and addressing these challenges, it is possible to improve accuracy and ethics in billing health care services.
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