Comprehensive Error Rate Testing
CERT Error Focus - Evaluation and Management - CPT 99211
In recent Communiqué articles, we have focused on CERT errors received by specific provider specialties. In our continuing effort to increase the awareness of all Medicare providers regarding documentation issues found as a result of CERT reviews, we will now begin to focus on specific services that contribute to our CERT error rate. Our focus this month is on CPT procedure code 99211.
The 2006 Current Procedural Terminology (CPT) manual defines code 99211 as an "Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services."
Analysis of our recent CERT error findings shows that in some cases, this evaluation and management service was billed inappropriately. This resulted in CERT errors assessed for insufficient documentation and refund requests of the Medicare payment for the undocumented services.
Below are examples of the CERT reviewer comments in these cases.
- Injection sheet with beneficiary's name recorded and billing roster submitted for the billed date of service. Submitted is documentation of B12 injection. Missing documentation of a face to face encounter with exchange of clinically relevant information that supports a separate evaluation & management service.
- Need a copy of office notes for [DOS] to support billed services. Submitted lab results of CBC with diff., missing documentation to support billed service of 99211. Missing progress notes or any documentation to support E/M service billed.
- Per CPT 2005 and PUB 100-04, Chapter 12 § 30.6.4, documentation includes PT/INR results for date of service, but no indication of presenting problem by patient or nurse education/counseling needed for 99211 to be medically necessary.
- Need a copy of nurse's notes or some documentation for [DOS] to support billed E/M 99211. Submitted notes for other dates of service and prothrombin time results for billed DOS. Additional documentation not received. Missing documentation to support E/M 99211 examples vital signs, weight, how patient is doing, etc.....
- Per CPT 2005 and IOM 100-4, ch 12, 30.6.1, "Physicians must select the code for the service based upon the content of the service" and goes on to state, "A claim for a service must reflect the service actually performed." Flow sheet contains only the results of the test. There is insufficient documentation to indicate that any E/M service was performed. It would appear that the encounter was exclusively for the purpose of venipuncture. Claim history shows billing for PT lab for same date of service.
- Need documentation of the face-to-face evaluation & management service such as vital signs and/or patient teaching for [DOS] to support billed E/M service. Submitted is a lab report for INR on the billed DOS. Documentation does not indicate the beneficiary is being evaluated for a related problem or symptom and there is no medical evaluation & management of the problem. Documentation does not substantiate the billed E/M service.
Services billed to Medicare under CPT 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury. Furthermore, a face to face encounter with a patient consisting of elements of both evaluation and management is required. The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient. The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).
CPT 99211 should not be used for:
- Phone calls to patients
- Drawing of blood for laboratory analysis or when performing other diagnostic tests
- Administration of medications when an injection or infusion code is submitted separately
Proper documentation of services billed to Medicare is crucial in order to meet CMS' error rate reduction expectations, and WPS continues to identify problem areas contributing most significantly to our jurisdiction's error rate. It is our expectation that these educational efforts will result in a reductions of errors associated with these problem areas.
For more information regarding the CERT program and other issues related to CERT review findings, please visit our Website.
