Are You Billing these Evaluation and Management (E/M) Services Correctly?

Review of recent Comprehensive Error Rate Testing (CERT) findings for WPS Medicare reveals three E/M CPT® codes (with ten or more services reviewed in the sample) were incorrectly coded at a rate of at least 30%. The chart below illustrates these procedure codes and percentage of cases for which the medical records submitted did not support the level of service billed. Select a CPT code below to navigate directly to CERT error examples for the selected code, or scroll down to view examples for all codes.

CPT® Code Reviewed by CERT Contractor
(Claims submitted 07/01/10-06/30/11)		 Percentage of Services Incorrectly Coded
99233 - Subsequent hospital care, per day, for the evaluation and management of a patient 38%
99223 - Initial hospital care, per day, for the evaluation and management of a patient 33%
99285 - Emergency department visit for the evaluation and management of a patient 30%

CPT Code 99233 - CERT Error Examples:

  • CPT code 99233, subsequent hospital care visit, requires 2 of 3 components; detailed history, detailed exam, and high complexity medical decision making. Documentation supports 99231, with 2 of 3 components; problem focused history, expanded problem focused examination, and straight forward medical decision making. Down code from 99233 to 99231.
  • Documentation supports code change from 99233 to 99232 with expanded problem focused history and exam, and moderate complexity medical decision making.
  • Documentation supports a down code from 99233 to 99232 as billed with Expanded Problem Focused History (1 HPI/2 ROS) per 1995 and 1997 E/M guidelines, Detailed Exam, and Moderate complexity MDM per 1995 and 1997 E/M guidelines.

CPT Code 99223 - CERT Error Examples:

  • Billed CPT 99223, which requires 3 of 3 components: comprehensive history, comprehensive exam and high complexity medical decision making (MDM). Documentation supports 99221 with detailed history, comprehensive exam, moderate complexity MDM.
  • Per CERT Medical Director "The HCPCS code billed by the provider does not meet the minimum requirements for the E/M category billed (i.e., does not meet 2 of 3, or 3 of 3 depending on the category billed) of the E/M CPT codes as defined by the 1995 and 1997 CMS guidelines for Evaluation and Management Codes. Therefore, using the documentation provided by the billing provider, an assignment of E/M code 99499 has been assigned with payment calculated based on determination by Medical Director. Documentation submitted includes EPF history, EPF exam, moderate complexity MDM.
  • Documentation supports a down code from 99223 to 99221 as billed with detailed history (4 HPI/3 ROS/3 Hx) per 1995 and 1997 E/M guidelines, comprehensive exam per 1995 E/M guidelines, and moderate complexity MDM per 1995 and 1997 E/M guidelines.

CPT Code 99285 - CERT Error Examples:

  • Billed is CPT 99285 New or Established Patient for ER visit that requires 3 of 3 key components (comprehensive history, comprehensive exam, and high complexity medical decision making). Documentation supports comprehensive history and exam, and moderated complexity MDM per 1995 E/M guidelines. Documentation reveals that Beneficiary seen in the emergency room due to flank pain and discharged. Noted moderate medical decision making therefore will change code from 99285 to 99284.
  • Documentation supports a down code to CPT 99284 with comprehensive history, comprehensive exam, and moderate complexity MDM.
  • Documentation supports a down code from 99285 to 99284 as billed with detailed history (4 HPI/4ROS/1 Hx) per 1995 and 1997 E.M guidelines, comprehensive exam per 1995 E/M guidelines, and moderate complexity MDM per 1995 E/M guidelines.

We closely monitor our CERT errors in order to identify problem areas contributing most significantly to our jurisdiction's error rate. Providers with error findings may be the subject of additional review and educational contacts by WPS Medicare or other CMS affiliated contractors.

If you bill E/M services to Medicare, we highly recommend performing a self-audit of your billing and documentation processes. If Medicare overpayments are discovered, you can find instructions for submitting voluntary refunds on our Financial web page.

Be sure to visit our Evaluation and Management web page for more information on the proper billing and documentation of these services. Our "E/M Coding Guide" (available on the Evaluation & Management under Provider Specialties/Services on our Resources page) can assist you with the identification of appropriate E/M codes.

Page Last Updated: Friday, 06-Apr-2012 08:05:59 CDT