Service Specific Probe Results for Subsequent Hospital Care CPT Code 99233 - Family Practice, Specialty 08

Subsequent Hospital Care services continue to be a focus area for the Fiscal Year (FY) 2011 Medical Review Strategy. Analysis of claims in the November 2010 sample period reveals there were 160 Evaluation and Management (E/M) Comprehensive Error Rate Testing (CERT) errors. One hundred thirty three (133) of those errors were for incorrectly coded services. Berenson-Eggers Type of Service M2B (BETOS) Category - Subsequent Hospital Care had the highest number of total errors in comparison to the other E/M BETOS categories including 24 errors (18.05%) for incorrectly coded services.

Please refer to the notification article entitled "Planned Widespread Service-Specific Probe Reviews for Subsequent Hospital Visits (CPT 99233)" for the entire explanation of how these services were chosen for medical review.

A claim sample was obtained from the Legacy Jurisdiction (Illinois, Michigan, Minnesota and Wisconsin) for Specialty 08, Family Practice. Widespread, service-specific probes are conducted to validate potential systemic problems with billing, utilization, and/or documentation of a specific service.

Records were reviewed to determine whether the procedure code billed met all documentation requirements for the service billed. Services for CPT Code 99233 were denied or reduced if documentation did not support the service billed as defined in Internet Only Manual (IOM) 100-04, Chapter 12Adobe Portable Document Format, Section 30.6, Evaluation and Management Service Codes - General (Codes 99201 - 99499), located on the Centers for Medicare & Medicaid Services (CMS) website.

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 99233 requires at least two of these three key components:

  • A detailed interval history;
  • A detailed examination;
  • Medical decision making of high 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 patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit. Current Procedural Terminology 2009 and 2010 American Association. All Rights Reserved.

Review Results

A total of 157 services (from 100 claims) for CPT code 99233 were randomly selected for Prepayment review with no more than five (5) claims from any provider or group. Of these 157 services, 44 services (28.03%) were allowed as billed. The remaining 113 services (71.97%) were denied as follows:

  • Requested documentation was not received, 59.87%;
  • Documentation did not support the level of service billed, 12.10%.

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 (2) of the three (3) Key Components for CPT code 99233;
  • 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:

  • Requested documentation was not received
  • Documentation did not support the level of service billed

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 99233 Specialty 08 is 64.28%.

The major issues identified that led to the denial of 71.97% of these services are as follows:

  1. Documentation was not received

    If documentation is requested by WPS or another CMS agency, it is the provider's responsibility to supply the requested information within the allotted time. Services for which documentation is not received within 45 days are denied, and are included in the PCA Error Rate.

    The Overall Denial Rate for the Legacy Jurisdiction for this issue is 59.87%.

  2. Incorrectly Coded - Documentation Did Not Support Level of Service Billed

    Billed services must meet the Medicare guidelines, as well as all 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 service billed. There are three Key Components (History, Examination, and Medical Decision-Making) to be considered when selecting the appropriate level of E/M service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the floor/unit time in the hospital is spent providing counseling or coordination of care. The extent of the counseling and/or coordination of care must be documented in the medical record.

    The Overall Denial Rate for the Legacy Jurisdiction for the issue of documentation not supporting the level of service billed is 12.10%.

    Selection of Level of Evaluation and Management Services

    IOM 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 require a higher level of decision making than that required the level of the service billed. (The levels of the 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 (4) 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 comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

    All three (3) Components must be considered when determining the overall level of Medical Decision Making.

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.

A Comparative Billing Report for CPT Code 99233 compares the WPS carrier utilization for the WPS Legacy States (Illinois, Michigan, Minnesota and Wisconsin) to the national utilization (all states) for Specialty 08 (Family Practice) within the code range for CPT Codes 99231 - 99233. The BESS Data (Part B Extract and Summary System) is obtained from the Centers for Medicare & Medicaid Services (CMS). This data shows that the WPS carrier allowed fewer services than the national allowed services for CPT Code 99233. This chart is available on the WPS Medicare website.

To review the current educational material available on the WPS Medicare website for Evaluation and Management Services, please visit the Provider Specialties/Services area within the Resources section of the WPS Medicare 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, 27-Jan-2012 15:45:13 CST