GOVERNMENT & MEDICINE
Primary care troubled by coding errors
Medicare officials suggest doctors may have trouble deciphering evaluation and management guidelines in billing.
By Markian Hawryluk, AMNews staff. Dec. 8, 2003.
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Washington -- New data on the percentage of Medicare claims submitted and paid improperly show primary care physicians and carriers are struggling with the complexity of coding and billing regulations, physician groups said.
In November, the Centers for Medicare & Medicaid Services announced a national error rate for fiscal year 2003 of 5.8%, representing about $11.6 billion in Medicare spending. The Health and Human Services Office of Inspector General, which had conducted the review in past years, reported an improper payment rate of 6.3% in 2001 and 2002.
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Getting the error rate down
Wrong claims and payments by specialty
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Topic: Medicare payment
While the error rate is often cited as a measure of fraud in the program, it is intended to quantify the percentage of claims not paid properly under Medicare billing rules. Those include services that were legitimately provided but improperly billed. It also includes such mistakes as using the wrong code or not providing sufficient documentation to show that a service was medically necessary.
For the first time, the survey calculated specialty-specific error rates. CMS now plans to focus its corrective efforts on those categories or types of health care practitioners with high percentages of improper claims.
The physician specialties with the highest rates include many of the primary care specialties that tend to bill more for evaluation and management services than for other procedures. Internists, general physicians and family physicians had error rates of 20% or higher for submitted claims, while Medicare carrier error rates for reimbursement to those specialties were 16% or higher.
"I would expect it would have something to do with E&M guidelines," said Leslie Norwalk, CMS deputy administrator and chief operating officer. "I've certainly heard plenty from that particular community about how difficult it is to get it right."
A reclassification of claims changed CMS' error rate from 9.8% to 5.8%.
The American College of Physicians said, given the difficulty even experienced professionals have with E&M coding, CMS should not include in the improper payment rate E&M coding errors if there is only a one-level discrepancy in the code. In a letter to CMS, the college cited a 1995 study in which the OIG asked eight Medicare carriers to code five hypothetical patient office visits. None of the five examples were coded the same way by all eight carriers.
ACP also questioned whether the contractor reviewing the claims had sufficient expertise to accurately review E&M service claims.
The American Academy of Family Physicians said the error rate reflected the complexity that primary care physicians face.
"If you look at our scope of practice, it is the [entire] code book," said AAFP President Michael Fleming, MD. "It's so broad that there is much more potential for billing error."
Dr. Fleming said widespread implementation of electronic health records integrated with billing systems would help reduce problem claims. "It's an area that we want to see drop," he said. "If we can encourage physicians to utilize technology, specifically an electronic health record, we think that will go a long way toward decreasing these billing mistakes."
The results of the improper payment review indicate much work still must be done to identify and prevent errors, CMS Administrator Tom Scully said. "Now that CMS has detailed error rates, we can aggressively target our efforts by strengthening the management of our contractors and concentrating on the problems indicated by the error rate. Our goal is to bring about a dramatic reduction in Medicare payment errors in the next 24 months."
Controversy over the numbers
The agency's effort to get more detail about the accuracy of claims processing by Medicare carriers, however, sparked questions about the validity of the new method for calculating the percentage of improper payments.
The OIG surveys through 2002 were based on about 6,000 claims. This year, Medicare hired a private contractor to review about 128,000 claims and provide a detailed breakdown of the error rate by carrier, by type of health care practitioner, and by physician specialty. Improper payment rates by CPT code will be released in December.
The error rate has gone down each year since 1996.
But CMS' contractor ran into difficulty getting physicians and other health care professionals to send in the medical records it needed to review the claims. For about 5% of the claims, the practitioner did not respond to the request for the medical records. Had the contractor classified all those payments as improper, the error rate would have been 9.8%.
Norwalk said there could be a number of reasons why those records were not provided -- everything from concerns about violating patient privacy laws to not having the right address. The cost of the task could have been an issue for physician practices, she said. A doctor might balk at spending $30 in nurse time to pull a medical record for a claim that paid only $3, she added.
"It's not really economically viable for you to go and do all that work to pull all those claims that you've got somewhere in storage," Norwalk said.
CMS decided to reclassify those 5% of claims based on previous experience, and as a result revised the 9.8% error rate to 5.8%. Senate Finance Committee Chair Charles Grassley (R, Iowa) blasted the decision and called on the OIG to monitor CMS' error rate calculations.
"It appears that the unadjusted error rate of close to 10% was too high for CMS -- almost four percentage points higher than in the previous two years," Grassley said. "So CMS reports that it adjusted that figure downward to the 5.8%."
Norwalk countered that despite the problem in determining an overall rate, the more detailed analysis provides CMS with a tool to address the problem.
"Yeah, it'd be nice if we had the statistical number perfect, but my issue from a management perspective is making sure we pay those billions of claims accurately," she said.
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ADDITIONAL INFORMATION:
Getting the error rate down
Medicare has made steady progress in reducing the rate of improper payments since it first began calculating the number in 1996.
National paid claims error rate:
Fiscal
Year Rate
1996 13.8%
1997 11.4%
1998 7.1%
1999 8.0%
2000 6.8%
2001 6.3%
2002 6.3%
2003 5.8%
Source: Centers for Medicare & Medicaid Services (Fiscal 2003 calculation includes a revision to account for 5% of claims for which medical records were not submitted.)
Wrong claims and payments by specialty
Confusion over Medicare coding guidelines could be partly to blame for generally higher rates of both improper claims submission and payment in primary care, government officials speculate.
improperly Submitted improperly Paid
Internists 26.38% 23.16%
General physicians 22.12% 18.25%
Urologists 21.34% 8.86%
Hematologists/oncologists 21.09% 9.96%
Family physicians 19.92% 16.54%
Cardiologists 19.15% 14.97%
Diagnostic radiologists 18.11% 10.71%
Ophthalmologists 14.31% 5.60%
Source: Centers for Medicare & Medicaid Services
Weblink
Centers for Medicare & Medicaid Services' Comprehensive Error Rate Testing (CERT) program (www.cms.hhs.gov/providers/psc/cert.asp)
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Tuesday, December 23, 2003
Surgeons "Vote With Their Feet" for Sentinel Node Biopsy for Breast Cancer Staging
Tracy Hampton, PhD
JAMA. 2003;290:3053-3054.
Sentinel node biopsy (SNB), an investigational procedure for staging breast cancer that involves substantially less morbidity than standard axillary node dissection, is now routinely performed despite the fact that clinical trials to test its validity are still years from completion, according to a new study in the Journal of the National Cancer Institute (J Natl Cancer Inst. 2003;95:1514-1521).
The study, which involved 3003 women with stage 1 or stage 2 breast cancer who were treated at five comprehensive cancer centers between 1997 and 2000, reports that the use of SNB increased from 8% in 1997 to 58% in the last half of 2000.
Surgeons estimate that SNB is even more prevalent today, and its appeal is obvious. Axillary node dissection, which is removal of all the axillary lymph nodes to examine them for the presence of metastatic cancer cells, can leave women with arm pain and swelling for months to years—effects that are significantly reduced with the less invasive SNB. In the latter procedure, surgeons remove only one or a few "sentinel" lymph nodes that are the first nodes to filter fluids draining from the breast tumor tissue. Only if cancer is found in those few nodes will women have to undergo full axillary node dissection; if cancer is not found, the presumption is that the other nodes are also negative, and the patient is able to avoid axillary node dissection.
Sentinel node biopsy for breast cancer involves injecting dye and/or radioisotope into tissue surrounding a tumor. The material migrates to draining lymph nodes, allowing the surgeon to identify and remove them; nodes are analyzed to determine whether the cancer has metastasized. In axillary node dissection, all regional lymph nodes are removed for analysis.
Several extensive studies comparing the accuracy of sentinel and axillary procedures were initiated by the National Cancer Institute in 1999, and they will not be complete until 2007. But in the meantime, breast cancer surgeons were encouraged by studies of SNB (followed by axillary node dissection) at various hospitals that indicated that SNB accurately predicts the status of the remaining axillary nodes over 90% of the time (Breast Cancer Res Treat. 2001;3:104-108; Zentralbl Gynakol. 2003;125:335-337), and widespread adoption of investigational SNB over the standard axillary procedure as the initial staging procedure followed.
But the Journal of the National Cancer Institute study raises the question: Should surgeons wait for randomized clinical trials to end before performing SNB on a regular basis?
"Thinking, careful surgeons who are dedicated to clinical trials have clearly voted with their feet on this question," said lead author Stephen Edge, MD, of the Roswell Park Cancer Institute, in Buffalo. "We're not making a value judgment about whether they are right or wrong. But because this is happening, it seems that we need to look for ways other than clinical trials to test new technologies like SNB," he said.
Hiram Cody III, MD, of the Memorial Sloan-Kettering Cancer Center, in New York, is neither surprised nor concerned that SNB has been widely adopted before clinical trials are complete.
"There's a wealth of observational data; I think the concern that it's been adopted prematurely is overblown, he said. "All of us who do it as standard care are very comfortable doing it."
Cody argued that SNB does not require randomized clinical trials because, in his view, the accuracy of the procedure has already been proven. But he said that the trials will answer some important questions, such as the rate of axillary recurrence after a negative SNB, which some studies claim to be less than 1%.
This information will be valuable as physicians and their patients discuss the pros and cons of SNB and axillary node dissection. Currently, patients can weigh their options based on the experience of their surgeons and outcome data from small, institutional studies. The ongoing trials, however, may provide more definitive information about whether the choice of SNB vs axillary node dissection will affect recurrence and mortality.
Weighing Risk
Research suggests that even a small reduction in survival may be of greater concern than morbidity for many women. In one survey, only one third to one half of the women surveyed said they would choose SNB if SNB had a 1 in 1000 increased risk of death at 5 years over axillary node dissection (ANZ J Surg. 2002;72:110-113).
There are no long-term survival data comparing SNB and axillary node dissection, which raises some concerns that women with metastatic breast cancer might fall through the cracks as a result of SNB false-negative results. But surgeons stress that even a negative SNB is usually followed up with therapy and close monitoring, reducing this risk.
"The actual clinical rate of nodal recurrence is lower than the false-negative rate because in some cases cancer cells in the nodes are killed by radiation, chemotherapy, or tamoxifen," said Monica Morrow, MD, of Northwestern University Medical School, in Chicago.
A positive SNB might warrant more or different types of chemotherapy than standard adjuvant therapy. Even so, Edge said, "Women who have [axillary node dissection] have a similar false-negative rate and the same risk for having undertreatment." Results from the ongoing clinical trials may help resolve this issue.
PATIENT ACCRUAL FOR TRIALS
Researchers caution that the widespread acceptance of medical procedures before completion of clinical trials should be done only under rare circumstances—both for the sake of the patients and for the sake of science.
Lessons from the past have made that clear. Back in the 1990s, high-dose chemotherapy followed by stem-cell transplantation looked like a promising therapy for metastatic breast cancer. As women flocked to hospitals that would provide the treatment outside of the framework of a randomized trial, researchers had a difficult time accruing patients to the studies. Ultimately, the trials proved that the experimental therapy did not improve survival; in fact, treatment-related toxicity was, in some cases, deadly to patients (J Natl Cancer Inst. 2000;92:225-233; N Engl J Med. 2000;342:1069-1076).
The issue of adopting SNB before waiting for clinical trial results "is different than the chemotherapy/stem cell incident, though," said Morrow. "SNB is a diagnostic tool, not a therapy. And if a node comes up positive, then the surgeon will follow up with the standard axillary dissection," she said.
Also unlike the chemotherapy/stem cell case, the widespread use of SNB does not seem to be affecting patient enrollment in clinical trials; most trials have completed accrual or are near completion. The exception is a study of patients with an SNB indicating the presence of cancer cells in the sentinel node who are randomized to either observation or axillary node dissection; accrual could be slow because both patients and physicians may be reluctant to leave remaining nodes alone if the sentinel node tests positive.
William Gradishar, MD, also of Northwestern, says that particular trial will provide some of the most valuable information about SNB, though. "The question is, if a sentinel node is positive, do you really need to do [axillary node dissection]?" he asked. "The standard of care today is that it should be done, but if it doesn't affect the outcome or subsequent treatment, we would like to eliminate it because of its adverse effects."
SURGICAL SKILL
One caveat about SNB, say experts, is that its reliability depends on the experience of the surgical team. Some reports claim that most false-negative results occurred within the first six cases of each surgeon (Ann Surg. 1999;229:723-728), but other studies have found that surgeons required an average of 23 cases to achieve 90% success and 53 cases to achieve 95% success (Ann Surg Oncol. 1999;6:553-561).
Cody said, however, that because SNB is being done with greater frequency each year, the technique has become more routine and standardized. "The learning curve may not be as long as we first thought," he said.
Currently, surgical teams learning the technique typically do a backup axillary node dissection until they have proven their skills at accurately locating and analyzing sentinel lymph nodes. But subjecting patients to axillary node dissection following SNB for training purposes alone is problematic, said Gradishar. Instead, some hospitals are asking veteran surgeons to closely supervise new surgeons during SNB until they are proficient.
Tracy Hampton, PhD
JAMA. 2003;290:3053-3054.
Sentinel node biopsy (SNB), an investigational procedure for staging breast cancer that involves substantially less morbidity than standard axillary node dissection, is now routinely performed despite the fact that clinical trials to test its validity are still years from completion, according to a new study in the Journal of the National Cancer Institute (J Natl Cancer Inst. 2003;95:1514-1521).
The study, which involved 3003 women with stage 1 or stage 2 breast cancer who were treated at five comprehensive cancer centers between 1997 and 2000, reports that the use of SNB increased from 8% in 1997 to 58% in the last half of 2000.
Surgeons estimate that SNB is even more prevalent today, and its appeal is obvious. Axillary node dissection, which is removal of all the axillary lymph nodes to examine them for the presence of metastatic cancer cells, can leave women with arm pain and swelling for months to years—effects that are significantly reduced with the less invasive SNB. In the latter procedure, surgeons remove only one or a few "sentinel" lymph nodes that are the first nodes to filter fluids draining from the breast tumor tissue. Only if cancer is found in those few nodes will women have to undergo full axillary node dissection; if cancer is not found, the presumption is that the other nodes are also negative, and the patient is able to avoid axillary node dissection.
Sentinel node biopsy for breast cancer involves injecting dye and/or radioisotope into tissue surrounding a tumor. The material migrates to draining lymph nodes, allowing the surgeon to identify and remove them; nodes are analyzed to determine whether the cancer has metastasized. In axillary node dissection, all regional lymph nodes are removed for analysis.
Several extensive studies comparing the accuracy of sentinel and axillary procedures were initiated by the National Cancer Institute in 1999, and they will not be complete until 2007. But in the meantime, breast cancer surgeons were encouraged by studies of SNB (followed by axillary node dissection) at various hospitals that indicated that SNB accurately predicts the status of the remaining axillary nodes over 90% of the time (Breast Cancer Res Treat. 2001;3:104-108; Zentralbl Gynakol. 2003;125:335-337), and widespread adoption of investigational SNB over the standard axillary procedure as the initial staging procedure followed.
But the Journal of the National Cancer Institute study raises the question: Should surgeons wait for randomized clinical trials to end before performing SNB on a regular basis?
"Thinking, careful surgeons who are dedicated to clinical trials have clearly voted with their feet on this question," said lead author Stephen Edge, MD, of the Roswell Park Cancer Institute, in Buffalo. "We're not making a value judgment about whether they are right or wrong. But because this is happening, it seems that we need to look for ways other than clinical trials to test new technologies like SNB," he said.
Hiram Cody III, MD, of the Memorial Sloan-Kettering Cancer Center, in New York, is neither surprised nor concerned that SNB has been widely adopted before clinical trials are complete.
"There's a wealth of observational data; I think the concern that it's been adopted prematurely is overblown, he said. "All of us who do it as standard care are very comfortable doing it."
Cody argued that SNB does not require randomized clinical trials because, in his view, the accuracy of the procedure has already been proven. But he said that the trials will answer some important questions, such as the rate of axillary recurrence after a negative SNB, which some studies claim to be less than 1%.
This information will be valuable as physicians and their patients discuss the pros and cons of SNB and axillary node dissection. Currently, patients can weigh their options based on the experience of their surgeons and outcome data from small, institutional studies. The ongoing trials, however, may provide more definitive information about whether the choice of SNB vs axillary node dissection will affect recurrence and mortality.
Weighing Risk
Research suggests that even a small reduction in survival may be of greater concern than morbidity for many women. In one survey, only one third to one half of the women surveyed said they would choose SNB if SNB had a 1 in 1000 increased risk of death at 5 years over axillary node dissection (ANZ J Surg. 2002;72:110-113).
There are no long-term survival data comparing SNB and axillary node dissection, which raises some concerns that women with metastatic breast cancer might fall through the cracks as a result of SNB false-negative results. But surgeons stress that even a negative SNB is usually followed up with therapy and close monitoring, reducing this risk.
"The actual clinical rate of nodal recurrence is lower than the false-negative rate because in some cases cancer cells in the nodes are killed by radiation, chemotherapy, or tamoxifen," said Monica Morrow, MD, of Northwestern University Medical School, in Chicago.
A positive SNB might warrant more or different types of chemotherapy than standard adjuvant therapy. Even so, Edge said, "Women who have [axillary node dissection] have a similar false-negative rate and the same risk for having undertreatment." Results from the ongoing clinical trials may help resolve this issue.
PATIENT ACCRUAL FOR TRIALS
Researchers caution that the widespread acceptance of medical procedures before completion of clinical trials should be done only under rare circumstances—both for the sake of the patients and for the sake of science.
Lessons from the past have made that clear. Back in the 1990s, high-dose chemotherapy followed by stem-cell transplantation looked like a promising therapy for metastatic breast cancer. As women flocked to hospitals that would provide the treatment outside of the framework of a randomized trial, researchers had a difficult time accruing patients to the studies. Ultimately, the trials proved that the experimental therapy did not improve survival; in fact, treatment-related toxicity was, in some cases, deadly to patients (J Natl Cancer Inst. 2000;92:225-233; N Engl J Med. 2000;342:1069-1076).
The issue of adopting SNB before waiting for clinical trial results "is different than the chemotherapy/stem cell incident, though," said Morrow. "SNB is a diagnostic tool, not a therapy. And if a node comes up positive, then the surgeon will follow up with the standard axillary dissection," she said.
Also unlike the chemotherapy/stem cell case, the widespread use of SNB does not seem to be affecting patient enrollment in clinical trials; most trials have completed accrual or are near completion. The exception is a study of patients with an SNB indicating the presence of cancer cells in the sentinel node who are randomized to either observation or axillary node dissection; accrual could be slow because both patients and physicians may be reluctant to leave remaining nodes alone if the sentinel node tests positive.
William Gradishar, MD, also of Northwestern, says that particular trial will provide some of the most valuable information about SNB, though. "The question is, if a sentinel node is positive, do you really need to do [axillary node dissection]?" he asked. "The standard of care today is that it should be done, but if it doesn't affect the outcome or subsequent treatment, we would like to eliminate it because of its adverse effects."
SURGICAL SKILL
One caveat about SNB, say experts, is that its reliability depends on the experience of the surgical team. Some reports claim that most false-negative results occurred within the first six cases of each surgeon (Ann Surg. 1999;229:723-728), but other studies have found that surgeons required an average of 23 cases to achieve 90% success and 53 cases to achieve 95% success (Ann Surg Oncol. 1999;6:553-561).
Cody said, however, that because SNB is being done with greater frequency each year, the technique has become more routine and standardized. "The learning curve may not be as long as we first thought," he said.
Currently, surgical teams learning the technique typically do a backup axillary node dissection until they have proven their skills at accurately locating and analyzing sentinel lymph nodes. But subjecting patients to axillary node dissection following SNB for training purposes alone is problematic, said Gradishar. Instead, some hospitals are asking veteran surgeons to closely supervise new surgeons during SNB until they are proficient.
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