TrailBlazer (the MAC for Colorado, New Mexico, Oklahoma, Texas, and Virginia) recently identified potential improper utilization of established office visit services (codes 99211–99215) billed to Medicare. According to TrailBlazer, two widespread probe reviews were conducted to verify if this perceived improper utilization was actual or not. These reviews are called “widespread” becausedocumentation is evaluated from multiple providers. TrailBlazer used the Progressive Correction Action (PCA) process to identify a random sample of 200 claims (two reviews) containing established office visits with dates of service from January 1, 2010, through June 30, 2010. The selection of providers for this review was based on a scoring methodology that considered the following variables:
- Distribution of claims volume for CPT codes 99211–99215.
- Distribution of paid dollars for CPT codes 99211–99215.
- Percent of claims billed with modifier 25.
- Percent of claims billed with CPT codes 99211–99215 billed as 99214/99215.
- Frequency of services per beneficiary for CPT codes 99211–99215 compared to the peer average.
One probe review (100 claims) was conducted on selected providers in Virginia. The other probe review (100 claims) was conducted on selected providers in Colorado, New Mexico, Oklahoma and Texas.
The Probe’s Findings
Overall error rate for each probe review was:
Virginia: 51.43 percent.
Colorado, New Mexico, Oklahoma and Texas: 91.32 percent.
Findings Conclusion – Medicare expects providers who bill these services to:
- Bill an E/M service only when the service meets medical necessity requirements and document sufficiently to support the medical necessity of the E/M service billed. Medicare determines “medically reasonable and necessary” separately from determining the work described by a reported CPT code performed. The patient’s condition (severity, acuity, number of problems, etc.) is the key factor in determining medical necessity for Medicare payment for services.
- Bill the level of E/M service appropriate to treat the patient’s presenting problems. Documentation of E/M services billed for Medicare payment must ensure the patient’s clinical condition and reason for the service are documented in enough detail for a reasonable observer to understand the patient’s need and the practitioner’s thought process. The E/M code billed must reflect patient’s needs, work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.
- Medicare generally expects to see E/M services billed every three months for patients with chronic, stable conditions.
- Comply with the requirements for use of the 25 modifier. Modifier 25 is used when a significant, separately identifiable E/M service is performed by the same physician on the same day as a procedure or other service. The E/M service must meet the following criteria:
- Must have been performed and documented according to CPT code requirements and statutes concerning coverage and payment.
- Must be coded according to its medical necessity and documented CPT physician work.
- Must be a separately identifiable service provided on the same day, on the same patient and by the same practitioner as a therapeutic medical/surgical and/or diagnostic medical/surgical procedure with either a zero- or 10-day global period. The E/M service may result in the decision to perform a zero- or 10-day global procedure when the need to perform the procedure was not planned, was not foreseeable and the condition for which the procedure was necessary could not have been determined to exist without having performed the E/M service (i.e., new problem or new, previously undisclosed event related to a known problem).
- Must not have resulted in a decision to perform a major operative procedure (surgery).
- Must be a significant service, above and beyond the usual preoperative and postoperative work/care required by the therapeutic or diagnostic service also performed.