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Subsequent Hospital Care (GEN)
Posted December 19, 2007
The Medical Review Department recently conducted a service-specific review (SSR) of subsequent hospital care services (99233) billed by physicians of specialty 02 (General Surgery), 05 (Anesthesiology), 11 (Internal Medicine), 26 (Psychiatry), 29 (Pulmonary Disease), 33 (Thoracic Surgery), 39 (Nephrology), and 81 (Critical Care). A complete description of these codes may be found in the Current Procedural Terminology (CPT) Manual.
The Comprehensive Error Rate Testing (CERT) identified this procedure code as having the highest error rate nationally in the May 2007 Error Rate report.
This SSR (initiated in July 2007 and completed in November 2007) involved review of 100 claims (for dates of service October 1, 2006 - March 31, 2007) 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.
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 25 percent, with a down-coded/denial change rate of 68 percent. Below is a summary of the major issues and billing problems that were identified:
- Billing a higher level of evaluation and management (E/M) service than documentation supported. In most cases, the documentation did not support a medical decision making of high complexity.
- Documentation was not presented for the requested date of service.
- E/M service criteria that would allow for an E/M service to be billed were not met in the documentation.
- An incorrect procedure code was reported to Medicare.
- Handwriting was difficult to read or illegible.
Per Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6, "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 Documentation Guidelines for Evaluation and Management Services can be found at www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf, and the 1997 Documentation Guidelines for Evaluation and Management Services can be found at www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.
Per the 1995/1997 Documentation Guidelines for Evaluation and Management (E/M) Services, "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."
The 1995/1997 Documentation Guidelines for Evaluation and Management (E/M) Services also state, "The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician."
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.
For additional information about subsequent hospital care, please see the article titled, "Subsequent Hospital Care Evaluation and Management (E&M) Codes," which was published on page 3 of the December 2007 Medicare B Hotline Bulletin. |
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