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CMS recently posted detailed information on 2019 Medicare fee-for-service improper payments. One of many findings: 59.5% were caused by insufficient documentation. But some of the errors may be more about process than substance.[1] Visit https://go.cms.gov/2MgcnqR.
Table D4: Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS
Part A Hospital IPPS Services (MS-DRGs) | Projected Improper Payments | Improper Payment Rate | 95% Confidence Interval | Percentage of Service Type Improper Payments by Type of Error | Percent of Overall Improper Payments | ||||
---|---|---|---|---|---|---|---|---|---|
No Doc | Insufficient Doc | Medical Necessity | Incorrect Coding | Other | |||||
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity (469, 470) | $693,508,390 | 10.1% | 7.9% - 12.2% | 0.0% | 35.3% | 63.3% | 1.3% | 0.0% | 2.3% |
Psychoses (885) | $378,171,886 | 9.9% | 3.0% - 16.7% | 7.9% | 80.1% | 11.8% | 0.1% | 0.0% | 1.3% |
Septicemia Or Severe Sepsis WO MV >96 Hours (871, 872) | $275,840,496 | 3.1% | (1.9%) - 8.1% | 0.0% | 0.0% | 0.0% | 100.0% | 0.0% | 0.9% |
Endovascular Cardiac Valve Replacement (266, 267) | $236,231,903 | 12.3% | 6.4% - 18.1% | 0.0% | 83.7% | 6.1% | 0.8% | 9.4% | 0.8% |
Spinal Fusion Except Cervical (459, 460) | $164,937,576 | 8.7% | 1.3% - 16.2% | 0.0% | 31.9% | 40.8% | 27.3% | 0.0% | 0.6% |
Heart Failure & Shock (291, 292, 293) | $125,598,571 | 2.6% | 0.3% - 4.8% | 0.0% | 0.0% | 51.1% | 48.9% | 0.0% | 0.4% |
Organic Disturbances & Intellectual Disability (884) | $109,540,492 | 21.1% | 7.4% - 34.8% | 0.0% | 10.5% | 85.3% | 4.1% | 0.0% | 0.4% |
Degenerative Nervous System Disorders (056, 057) | $103,318,415 | 13.7% | 10.4% - 17.0% | 0.0% | 31.8% | 64.5% | 3.6% | 0.0% | 0.3% |
Esophagitis, Gastroent & Misc Digest Disorders (391, 392) | $88,617,581 | 7.6% | 3.5% - 11.8% | 7.3% | 0.0% | 92.6% | 0.1% | 0.0% | 0.3% |
Cardiac Arrhythmia & Conduction Disorders (308, 309, 310) | $85,869,565 | 6.6% | 3.1% - 10.1% | 0.0% | 0.0% | 89.7% | 10.3% | 0.0% | 0.3% |
Other Musculoskelet Sys & Conn Tiss O.R. Proc (515, 516, 517) | $81,117,774 | 19.1% | 7.7% - 30.5% | 0.0% | 0.0% | 97.4% | 2.6% | 0.0% | 0.3% |
Chest Pain (313) | $73,056,701 | 26.9% | 18.0% - 35.9% | 0.0% | 0.0% | 100.0% | 0.0% | 0.0% | 0.2% |
Kidney & Urinary Tract Infections (689, 690) | $72,819,946 | 4.7% | 0.5% - 8.9% | 0.0% | 0.0% | 86.0% | 14.0% | 0.0% | 0.2% |
Cervical Spinal Fusion (471, 472, 473) | $70,841,951 | 12.2% | 4.7% - 19.8% | 0.0% | 23.8% | 66.8% | 9.4% | 0.0% | 0.2% |
Extensive O.R. Procedure Unrelated To Principal Diagnosis (981, 982, 983) | $67,881,752 | 5.1% | 1.6% - 8.7% | 0.0% | 0.6% | 79.4% | 20.1% | 0.0% | 0.2% |
Percutaneous Intracardiac Procedures (273, 274) | $66,765,399 | 15.4% | 1.2% - 29.6% | 0.0% | 54.8% | 44.8% | 0.4% | 0.0% | 0.2% |
Lower Extrem & Humer Proc Except Hip, foot, femur (492, 493, 494) | $62,762,497 | 9.4% | 4.0% - 14.8% | 0.0% | 0.0% | 98.6% | 1.4% | 0.0% | 0.2% |
Signs & Symptoms (947, 948) | $57,215,765 | 20.8% | 11.4% - 30.2% | 2.1% | 4.8% | 80.6% | 12.5% | 0.0% | 0.2% |
Seizures (100, 101) | $53,402,312 | 10.9% | 3.4% - 18.3% | 0.0% | 0.0% | 73.2% | 26.8% | 0.0% | 0.2% |
Cardiac Defibrillator Implant WO Cardiac Cath (226, 227) | $53,375,432 | 13.3% | 7.9% - 18.7% | 0.0% | 17.9% | 73.2% | 8.9% | 0.0% | 0.2% |
All Type of Services (Incl. Codes Not Listed) |
$5,273,215,801 |
4.2% |
3.7% - 4.8% |
1.0% |
21.0% |
59.0% |
18.5% |
0.5% |
17.7% |