Service Specific Prepayment Probe Results for Established Patient Office Visits for the State of Illinois CPT Code 99213 - (All Specialties)

Established Patient Office Visits are a focus for the FY 2010 Medical Review Strategy. Analysis of claims from the Legacy Jurisdiction in the May 2009 sample period reveals there were 217 Comprehensive Error Rate Testing (CERT) errors. Of this number, 135 (62.21%) were for Berenson-Eggers Type of Service (BETOS) categories primarily reporting Evaluation and Management (E/M) procedure codes. Approximately 82% of the CERT errors for E/M codes were for incorrectly coded services. BETOS Category M1B - Office Visits Established Patient had the second highest number of errors in comparison to the other E/M BETOS categories. Review of claims in the November 2009 sample period for BETOS Category M1B-Established Office Visits for the time frame of 04/01/2008 through 03/31/2009, revealed that established office visits accounted for 40% of the E/M CERT errors. Incorrectly coded services made up approximately 68% of the errors in this BETOS Category. CPT code 99213 comprised 21% of the incorrectly coded errors.

The claim sample for this Service-Specific Prepayment Probe was obtained from Illinois for all Specialties for CPT code 99213. Widespread, Service-Specific Probes are conducted to validate potential systemic problems with billing, utilization, and/or documentation of a specific service.

WPS reviewed records to determine whether the billed procedure code met all documentation requirements for the service billed. Services for CPT Code 99213 were denied or adjusted if documentation did not support the service billed, as defined in Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6, Evaluation and Management Service Codes - General (Codes 99201 - 99499), located on the CMS website at: http://www.cms.gov/manuals/downloads/clm104c12.pdfAdobe Portable Document Format

In addition, medical record documentation must meet the following criteria:

  • Must be legible;
  • Clearly identify patient, date of service, and who performed the service;
  • Accurately report all pertinent facts, findings, and observations;
  • Include appropriate diagnosis for the service provided;
  • Documentation must have a hand written or an electronic signature. Stamp signatures are not acceptable.

CPT Code 99213 requires at least two of these three key components:

  • An expanded problem focused history;
  • An expanded problem focused examination;
  • Medical decision making of low complexity.

Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Current Procedural Terminology © 2010 and 2011 American Medical Association. All Rights Reserved.

Review Results:

A total of 101 services (from 100 claims) for CPT 99213 were randomly selected from all specialties for prepayment review, with no more than five claims from any one provider. Of these 101 services, 49 services (48.51%) were allowed as billed. The remaining 52 services (51.49%) were denied as follows:

  • 28 services (27.72%) were denied because no documentation was submitted;
  • 23 services (22.77%) were denied because the documentation did not support the level of service billed;
  • 1 service was denied because the service did not support an E/M service was performed, documentation supported a procedure was performed. (0.99%)

Services were allowed as billed if the submitted documentation met the following criteria:

  • The documentation supported a face-to-face Evaluation and Management (E/M) service;
  • Documentation was for the billed date of service;
  • Documentation had a legible, hand-written signature or an approved electronic signature by the billing provider;
  • Documentation met or exceeded two of the three key components for CPT code 99213;
  • Documentation supported the medical necessity for the level of service billed.

Progressive Corrective Action (PCA) Error Rate

The PCA Error Rate was calculated on the identified errors resulting from the following:

  • Documentation not submitted by the billing provider.
  • Documentation did not support the services billed.
  • The service was not billed under the appropriate procedure code.

The PCA Error Rate is based on dollars denied for PCA issues and determines the corrective action implemented at the conclusion of a Service Specific Probe Review. The Overall PCA Error Rate for CPT Code 99213 - all Specialties, for the state of Illinois was 40.06%

The major issues identified that led to denial of 51.49% of these services are as follows:

  1. Documentation not received:

    If requested by WPS or another CMS agency, it is the provider's responsibility to supply the requested information. Services for which no documentation was received within 45 days were denied, and are included in the PCA Error Rate.

    The Overall Denial Rate for the state of Illinois for this issue was 27.72%

  2. A. Documentation did not support the level of the services billed:

    Billed services must meet the Medicare Guidelines, as well as the criteria set forth in the Physician's Current Procedural Terminology (CPT) Manual. Documentation should reflect the amount of work performed at the visit and should support the level of the service billed. Please remember that the medical necessity of a service is the over-reaching criterion for payment in addition to the individual requirements of a CPT Code. There are (3) Components (History, Examination, and Medical Decision Making) to be considered when selecting the appropriate level of an E/M service. The duration of the visit is an ancillary factor and does not control the level of service to be billed unless greater than 50% of the face-to-face time (for non-inpatient services) is spent providing counseling or coordination of care.

    Selection of Level of Evaluation and Management Service

    IOM (Internet Only Manual) Publication 100-04, Medicare Claims Processing Manual, 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."

    Just as it is inappropriate to bill a higher level of service than is required to manage the condition of the patient, it is also inappropriate to bill a lower level of service when the condition of the patient requires a higher level of decision making than that required for the level of service billed. (The levels of history and/or exam must also meet the key components for the higher level of service).

    According to the 1997 Evaluation and Management Guidelines, the levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

    • The number of possible diagnoses and/or the number of management options that must be considered.
    • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.
    • The risk of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

    All three components must be considered when determining the overall level of medical decision making.

    The Overall Denial Rate for the state of Illinois for this issue was 22.77%.

    B. Service not billed under the appropriate procedure code.

    IOM 100-04, Chapter 23, section 20.9 - Correct Coding Initiative (CCI), "The CMS developed the Correct Coding Initiative (CCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims." The CCI, itself, states in the Introduction for National Correct Coding Initiative Policy Manual for Medicare Services under Correct Coding that "Physicians must report services correctly." "Procedures should be reported with the most comprehensive CPT code that describes the services performed." And finally, "If a HCPCS/CPT code exists that describes the services performed; the physician must report this code rather than report a less comprehensive code…"

    The Overall Denial Rate for the state of Illinois for this issue was 0.99%.

Conclusion

Our philosophy at WPS Medicare is that providers want to bill Medicare correctly, and will do so if given the proper education and opportunity. Providers are encouraged to use this information to evaluate their own billing practices. Should issues be identified, providers are encouraged to implement appropriate self-corrective actions in their billing practices. To review the current educational material available on the WPS Medicare website for Evaluation and Management Services, please visit our On Demand Training page.

Comparative Billing Reports for CPT Code 99213 compare the WPS carrier utilization for the WPS Legacy States (Illinois, Michigan, Minnesota, and Wisconsin) to the national utilization (all states) for all Specialties within the code range for CPT Codes 99211 - 99215. The BESS Data (Part B Extract and Summary System) is obtained from the Centers for Medicare and Medicaid Services (CMS). The data shows the WPS carrier allowed services to be slightly less than the national allowed services for CPT Code 99213. This chart is available on the WPS Medicare Medical Review page of our website.

Information in this article is based on references as noted in IOM, PIM, Social Security Act, and Current Procedural Terminology (CPT). In the event of any discrepancy with the information in this article, the IOM is the final determinant.

Page Last Updated: Friday, 19-Aug-2011 15:42:42 CDT