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New Patient Office or Other Outpatient Visits for Podiatry Services (GEN)
Posted February 23, 2007
The Medical Review Department recently conducted a service-specific review (SSR) of new patient office or other outpatient visits procedure codes 99203-99205 billed by podiatrists (Specialty 48). A complete description of codes 99203-99205 may be found in the Current Procedural Terminology (CPT) Manual.
This SSR (initiated in September 2006 and completed in January 2007) involved review of 100 claims (for dates of service October 1, 2005 – July 31, 2006) chosen at random by our computer system. Medicare contractors conduct these reviews to identify widespread problems by monitoring usage of procedure codes among the provider community.
The decisions that resulted from this SSR were based on the following resources:
- 1995 Documentation Guidelines for Evaluation and Management Services.
- 1997 Documentation Guidelines for Evaluation and Management Services.
- Pub. 100-08, Medicare Program Integrity Manual, Chapter 3.
- Title XVIII of the Social Security Act, §1842(b)(18)(C) and (p)(1).
On completion of SSRs, a provider error rate is calculated. An explanation of how error rates are calculated may be accessed in the Medicare Program Integrity Manual, Chapter 3, §3.11.1.5.
The SSR resulted in an overall error rate of 19.4 percent, with a down-coded/denial change rate of 61 percent. Below is a summary of the major issues and billing problems that were identified:
- Documentation supported a lower level of evaluation and management (E/M) service.
- Diagnosis reported was not supported in the patient notes.
- Rendering provider signature was not identifiable.
Per the 1995/1997 Documentation Guidelines for Evaluation and Management Services:
“The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:
- history;
- examination;
- medical decision making;
- counseling;
- coordination of care;
- nature of presenting problem; and
- time.
The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counseling or coordination of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service.
Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (e.g., examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.”
Per Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.1(A):
“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. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”
The 1995/1997 Documentation Guidelines for Evaluation and Management Services, can be found at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp on the Centers for Medicare & Medicaid Services (CMS) Web site.
When billing Medicare for services rendered, providers are to follow Medicare guidelines which can be accessed on the CMS Web site at www.cms.hhs.gov/Manuals. |
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