The National Government Services Medical Review department conducted a service-specific prepayment audit for Jurisdiction K Part B claims in Connecticut and New York. The audit centered around evaluation and management (E&M) services that were billed with the current procedural terminology (CPT) for Initial Hospital Visits (99223) and Hospital Care Visits (99215).
Additionally, records will be reviewed to see if the procedure code billed meets all documentation requirements for the service billed. Services for CPT E&M codes can be denied or reduced if documentation does not support the service billed as defined by the CMS Internet-Only Manual (IOM) Publication 100-04, Medical Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners, Section 30.6, Evaluation and Management Services Codes-General (Codes 99201-99499).
The medical record documentation must also be legible, clearly identity the patient, date of service, and who performed the service, report all facts, findings, and observations, include appropriate diagnosis for the service, and the documentation must have a hand written or electronic signature (no stamp signatures).
Some results from the audit and recommendation are listed here:
Audit Findings Revealed for CPT 99215
- In June 2013 there were 958 services billed with 757 reduced/denied. Error rate was 79%.
- In July 2013 there were 969 services billed with 800 reduced/denied. Error rate was 82.6%.
- In August 2013 there were 1,073 services billed with 822 reduced/denied. Error rate was 76.6%.
Audit Findings Revealed for CPT 99233
- In June 2013 there were 2,067 services billed with 1,546 reduced/denied. Error rate was 74.8%.
- In July 2013 there were 2,031 services billed with 1,464 reduced/denied. Error rate was 72.1%.
- In August 2013 there were 2,329 services billed with 1,637 reduced/denied. Error rate was 70.3%.
Audit Findings Revealed for CPT 99223
- In June 2013 there were 261 services billed with 225 reduced/denied. Error rate was 86.2%.
- In July 2013 there were 245 services billed with 208 reduced/denied. Error rate was 84.9%.
- In August 2013 there were 292 services billed with 255 reduced/denied. Error rate was 87.3%.
For more audit results and more information, please see NGS article (link below).
Medical Necessity of E&M Services
Section 1862(a)(1)(A) of the SSA, “Exclusions From Coverage and Medicare as Secondary Payer” does not include expenses acquired for items and services which are not deemed necessary for the diagnosis or treatment of illness or injury. This applies to all services.
CMS IOS Publication 100-04, Chapter 12, Section 30.6.1 states:
“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”
For more information from NGS, please see here