Comprehensive Error Rate Testing
CERT Error Focus - Inpatient and Outpatient Initial Consultations - CPT 99241-99255
In previous Communiqué articles, we have focused on CERT errors received by specific provider specialties. In our continuing effort to increase the awareness of all Medicare providers regarding documentation issues found as a result of CERT reviews, we have begun to focus on specific services that contribute to our CERT error rate. Our focus this month is on incorrect coding issues related to initial consultation services, CPT procedure codes 99241-99255.
Analysis of current CERT error findings (claims submitted 04/01/05-03/31/06) show that these services accounted for nearly 20% of our errors assessed for incorrect coding. The majority of these cases involved services that were billed at a higher level than what was documented in the medical records. Below are examples of actual CERT review comments regarding these claims.
- Submitted documentation supports down code of 99254 to 99252 with detailed history, EPF exam, and Moderate complexity medical decision-making. The consulting MD was unable to communicate verbally due to "confused" beneficiary due to dementia; and was unable to examine the beneficiary due to "severe psychomotor agitation".
- Billed CPT 99254 requires 3/3 components of Comprehensive history and exam, and Moderate MDM with typically spending 80 minutes at patient bedside or on hospital unit with the presenting problem of moderate to high severity. Documentation submitted supports down-code to 99253 with detailed history and exam, and Moderate MDM with no time element documented. Cardiology consultant states, "Stable cardiac condition."
- Documentation supports down code from 99245 which requires 3 of 3, comprehensive history, comprehensive exam, and high complexity to 99243 by meeting 3 of 3 components with comprehensive history, detailed exam, and moderate complexity MDM.
Providers must be aware of documentation requirements when billing consultation services to Medicare Part B. The patient's medical records should be legible, contain the relevant history, physical findings conforming to the criteria stated in the "Indications and Limitation of Coverage" section of the Consultation NCP, and must be made available to the Carrier or CERT contractor upon request.
In addition, the consultant's written report should be legible, and should include the key components for the category, level, and location of service for the consultation performed. The E/M Documentation Guideline requirements for the consultation performed also must be met. Either the 1995 or the 1997 E/M Documentation Guidelines may be utilized, but the elements from each set of guidelines may not be mixed. The report should identify the referring physician/NPP and the reason for the consultation.
Proper documentation of services billed to Medicare is crucial in order to meet CMS' error rate reduction expectations, and WPS continues to identify problem areas contributing most significantly to our jurisdiction's error rate. Continued cooperation from providers in proper billing and documentation of services billed to Medicare is essential in order to reach these goals.
For more information regarding the CERT program and other issues related to CERT review findings, please visit our website. If you have questions related to the CERT process or a specific CERT sampled claim, you may email us at medicareadmin@wpsic.com. Be sure to include "CERT Question" in the subject line. Please also include your full name, telephone number, and Provider Identification Number (if available) in the body of the e-mail. This will assure a prompt and accurate reply to your question.
When e-mailing WPS Medicare, please do not include sensitive information. If your question pertains to a specific claim, include the Internal Control Number, not your patient's Medicare Health Insurance Claim Number.
For more information regarding Medicare coverage of consultation services, please refer to National Coverage Provision (NCP) - PHYS-006 on our WPS Medicare Website.
