Pre-Payment Audits of CPT99215, 99223, 99233: How to avoid decrease or denial of payment
As you know, National Government Services (NGS), our local Medicare Administrative Contractor, has identified certain codes and code combinations as having a high error rate for meeting documentation requirements. They refer to this initiative as a Medical Review Focus Area and have implemented a pre-payment audit for a random sampling of claims received for one of these “focus areas”.
One code selected for pre-payment review is CPT® 99215. This code represents a level five service for your established patients, and the medical record must contain either a comprehensive history or examination and medical decision making of high complexity. If counseling, education and coordination of care dominate the patient encounter, then CPT® 99215 correlates to 40 minutes. The documentation would need to reflect that at least half of the time was spent counseling along with the content of the discussion.
NGS released the results of its review for CPT® 99215 for the first quarter of 2016 on its website in May (link available at end of article). Out of the 2,279 services reviewed from January through March, there were 1,486 reduced to a lower level of service or denied. That is a 65% error rate, so we do not anticipate this code coming off of pre-payment review any time soon.
On the in-patient side, CPT® codes 99223 and 99233 are both subject to pre-payment audit. These codes are for the highest level of service for initial care and subsequent care. CPT® 99223 requires documentation of a comprehensive history, comprehensive examination, and medical decision making of high complexity. For subsequent care CPT® 99233, the record must contain either a detailed interval history or detailed examination and medical decision making of high complexity. If counseling, education and coordination of care dominate your subsequent visit, then CPT® 99233 correlates to 35 minutes, and the documentation requirements for billing based on time (as above) would have to be met.
Also available on the NGS website (link available at end of article) are the first quarter results for these codes. For the initial care CPT® 99223, there were 1,068 submissions reduced to a lower level of service or denied out of the 1,370 sampled. That is a 78% error rate. With subsequent care CPT® 99233, a 70% error rate was identified as 1,879 out of the 2,702 records were reduced or denied. Certainly, these codes will remain on pre-payment review with such a high rate of error.
There are other Medical Review Focus Areas in place for Connecticut, including certain vascular studies when billed in combination, some urine drug screening codes, and all prolonged services. As we look around to the other geographic areas served by NGS, we see additional pre-payment audits in place already. For example, the jurisdiction of New York has identified home visits provided by Podiatrists as an area of focus. In Maine, osteopathic manipulative therapy is subject to pre-payment audit.
We will continue to monitor the NGS focus areas and provide additional information as it becomes available. In the interim, as always, your careful documentation of the key components along with the medical necessity of these services will keep your records, and billing, compliant.
Link for NGS results for CPT® 99215:
Link for NGS results for CPT® 99223 and 99233: