Evaluation and Management (E/M) - WPS Medicare

Insufficient DocumentationEvaluation and Management (E/M) Services Billed to WPS Medicare - Part B~CERT Error Examples and How to Avoid Them~Error ExamplesBilled CPT 99211. Submitted documentation supports theonly face to face service provided on the billed date ofservice was venipuncture. No additional evaluation ormanagement service other than the beneficiary notificationto change current Coumadin dosing is documented.Billed CPT 99211 - Office or other outpatient visit for theevaluation and management of an established patient thatmay not require the presence of a physician, usually, thepresenting problem(s) are minimal, typically, 5 minutes arespent performing or supervising these services.Submitted note states, "Draw CBC." This does not supporta separately identifiable service from billed venipunctureon line 2 of this claim. Insufficient documentation tosupport service as billed.Billed CPT 99232. Submitted documentation includeshospital progress notes dated including the physicianassistant's signature and the billing provider signature onlydocumenting "agree". No face-to face service wasdocumented.How to prevent this type of errorServices billed to Medicare under CPT code 99211 must bereasonable and necessary for the diagnosis and treatment ofan illness or injury. Furthermore, a face-to-face encounterwith a patient consisting of elements of both evaluation andmanagement is required. The evaluation portion issubstantiated when the record includes documentation of aclinically relevant and necessary exchange of informationbetween provider and patient. The management portion issubstantiated when the record demonstrates an influence onpatient care (ex., medical decision making, patient education,etc.).CPT 99211 should not be used for: Phone calls to patients Drawing of blood for laboratory analysis or whenperforming other diagnostic testsAdministration of medications when an injection orinfusion code is submitted separatelyFor more information on this issue and other CERT errorfindings, visit our WPS Medicare CERT web page articles at:http://www.wpsmedicare.com/j5macpartb/departments/cert/cert_articles.shtmlRefer to CMS Internet-Only Manual, Publication 100-04,Chapter12, section 30.6.B which states, "if there was no faceto-faceencounter between the patient and the physician(e.g., even if the physician participated in the service by onlyreviewing the patient’s medical record) then the service mayonly be billed under the NPPs UPIN/PIN. Payment will bemade at the appropriate physician fee schedule rate basedon the UPIN/PIN entered on the claim."Billed CPT 99213. Submitted consists of procedural notefor iridectomy. Missing physician progress notes toMedicare does not pay for “incident to” services in aninpatient setting. For a split-shared visit, there must bedocumentation of the face-to-face portion of the E/Mencounter between the patient and the physician.Refer to the following resources for more guidance onthese services:WPS Medicare CERT web page article titled “InpatientSplit/Shared Evaluation and Management (E/M) Services” at:http://www.wpsmedicare.com/j5macpartb/departments/cert/2009_1116_em.shtmlRefer to the following sections in the CMS Internet-OnlyManual (IOM), Publication 100-04 Chapter 12: Section 30.6.1(B)(EM level of service - Shared/SplitService) Section 100.1(.1A) (MD/NPP Services in a TeachingSetting); Section 120.1 (Direct Billing for NPPs in the inpatientsetting)http://www.cms.gov/manuals/downloads/clm104c12.pdfAll services billed to Medicare must be documented in thepatient’s medical records and available for review uponHandout 3 www.wpsmedicare.com Page 1 of 4

support E/M service. Insufficient documentation to supportservice billed.Billed CPT 99222. Unable to support this claim asreasonable and necessary without supportingdocumentation. Submitted includes a discharge note, anoperative report, a team conference summary, a rehabflow sheet and progress notes unrelated to this date ofservice. Missing the evaluation and management for thisbilled claim.request. Avoid common documentation related denials withthese tips for services frequently billed to Medicare Part B at:http://www.wpsmedicare.com/j5macpartb/departments/cert/document-tips.shtmlServices billed were not renderedError ExamplesBilled CPT 99231. CERT informed by billing provider,"Upon review of our billing and documentation, we billed hospital visit in error. There is no documentationsubstantiating this service and billing. Therefore, I havevoided this charge and we will be refunding." Submittedincludes no documentation for claim from billing providerfor billed date of service.How to prevent this type of errorBilling errors continue to negatively impact CERT error rates.To avoid this type of error, we recommend periodic audits ofyour medical record documentation and billing process. If theMedicare payment is refunded prior to inclusion in a CERTsample, the last iteration of the claim will be reviewed and anerror will not be assessed for the original incorrectsubmission.Billed CPT 99238. Submitted documents include a letterfrom the rendering physician that states "Please beadvised that this was billed in error. I have voided thecharges." Claim is denied for lack of supportingdocumentation.Service Provided, but not by Billing ProviderError ExamplesHow to prevent this type of errorBilled CPT 99213 - E/M established patient requiring 2 Refer to CMS Internet-Only Manual, Publication 100-02,of 3 key components (expanded history and exam, and Chapter 15, section 60.2 atlow complexity medical decision making) was billed http://www.cms.gov/manuals/Downloads/bp102c15.pdf whichunder the physicians NPI. This service is being billed states in part "that there must have been a direct, personal,"Incident To" as the documentation for this date of professional service furnished by the physician to initiate theservice supports the service was performed by a nurse course of treatment of which the service being performed bypractitioner. The note shows this as a follow-up visit for the non-physician practitioner is an incidental part, and thereFibromyalgia/Chronic Fatigue/Right Lower Extremity must be subsequent services by the physician of a frequencyPain and to assess the patient after starting medication. that reflects the physician's continuing active participation inThe handwritten notes indicate previous visits with the and management of the course of treatment." Thesereason for the visit documented and a note for a requirements must be met and documented in the medicalsubsequent visit for f/u start Savella. Therecord for Medicare payment to be made for these services.documentation does not indicate any physicianoversight or previous visits by the physician initiating thecourse of treatment. Based on the documentation, itseems to be a follow-up visit with the NP who startedthe patient on this medication previously.31 – Service Incorrectly CodedError ExamplesE/M Services Coded to Lower Level by CERT ReviewerBilled CPT 99204 requires 3 of 3 key components(Comprehensive history and exam, and moderateHow to avoid this type of errorDocumentation for Evaluation and Management (E/M)services must support the level of service billed and themedical necessity of the level. A self-audit is an excellent wayfor a physician practice to ascertain if any problem areas existHandout 3 www.wpsmedicare.com Page 2 of 4