2024 CMS Improper Payment Data Released
What’s New: CMS has published its 2024 Medicare Fee-for-Service (FFS) Improper Payment Data, highlighting areas of billing and documentation vulnerability. This data, available in the latest MLN Newsletter (CMS MLN Newsletter, December 12, 2024), provides insight into which services, provider types, and settings are experiencing elevated error rates.
Why This Matters:
· Targeted Compliance Efforts: By identifying services with high improper payment rates, you can proactively refine your documentation and coding processes.
· Audit Preparedness: Knowing CMS’ focus areas helps you anticipate audits and implement corrective measures before problems arise.
· Quality & Revenue Integrity: Correct billing and documentation, ensure appropriate reimbursements, and maintain compliance with CMS regulations.
Key Highlights & Examples from the 2024 Data:
Evaluation and Management (E/M) Services: The report shows that certain E/M codes, such as 99214 (Established Patient Office Visit), continue to have error rates stemming from insufficient documentation. Providers should ensure that documentation includes all required elements—chief complaint, history, exam, and medical decision-making—to support the level of service billed.
Durable Medical Equipment (DME): The data frequently underscores improper payments related to DME, especially items requiring physician orders and face-to-face encounters (e.g., certain wheelchairs or diabetic testing supplies). Providers must verify that all required documentation—valid orders, proof of delivery, and necessary medical justification—is complete and easily retrievable.
Skilled Nursing Facility (SNF) and Home Health Claims: CMS data often points to recurring errors in documentation for SNF and home health services. Common issues include missing or incomplete assessments (e.g., Resident Assessment Instrument [RAI] for SNFs) and inadequate clinical documentation supporting the need for home health services. Ensuring accurate, thorough assessments and justifications is crucial for compliance.
Resource: Consult the CMS RAI Manual and Home Health Agency (HHA) Center
KZA Recommended Action Steps:
1. Review the 2024 CMS Improper Payment Findings: Access the full report via the CMS MLN Newsletter: 2024-12-12 MLN Newsletter
2. Conduct Internal Audits & Training: Evaluate your claims and documentation for the codes and services CMS identifies as high-risk. Offer refresher training for coding staff and clinicians to ensure compliance with the 2024 guidelines.
3. Update Policies & Procedures: Revise your internal policies based on the noted problem areas. This may include implementing standardized templates for high-volume E/M codes or reinforcing checklists for DME documentation.
4. Stay Informed: Regularly monitor CMS updates, MLN articles, and official Medicare guidance to adapt promptly to any new requirements or shifts in enforcement focus.
The KZA Bottom Line:
Leverage 2024 CMS Improper Payment Data to Strengthen Your Compliance!
The result of this analysis becomes the focus of Medicare audits by your MACS, and their audit partners. The considerable improper payments identified for E/M coding should be a wake-up call to evaluate your E/M documentation and coding to be audit-ready. Internal and external audits should be a top priority.
Contact us at KZAnow.com for assistance in auditing your coding and documentation.