Back in July, Medicare Administrative Contractor WPS-GHA randomly selected 100 Indiana and Michigan claims which contained CPT code 99285 for prepayment review. Shockingly, of these 100 services, only three (3.06 percent) were allowed as billed, and the remaining 97 (96.94 percent) were denied. What can we learn from these results?
Of course the recent probe by the Office of Inspector General into creeping E&M levels immediately comes to mind. Of the 100 claims, WPS-GHA said 67 were “not billed under the appropriate procedure code.” Most of these claims were subsequently downcoded and paid, but they still count as “denied” for purposes of the study.
Another 26 claims were denied because requested documentation was not provided. According to WPS-GHA, if information was requested, the documentation had to be received within 45 days or the claims were denied and counted in the PCA Error Rate. Similarly, 2 claims were denied because the service was not documented in the medical records.
What can we learn from these results?
First and most simply, responding to requests for documentation from payers in a timely manner is an essential function of managing the revenue cycle.
Second, don’t wait for the Centers for Medicare and Medicaid Services (CMS) to change the guidelines for evaluation and management codes, as they discussed in the 2018 Medicare Physician Fee Schedule Proposed Rule. Refresh yourself on the existing guidelines and be sure you are choosing the correct code based on the established criteria. If the documentation doesn’t support a 99285, don’t code and bill it.
Third, take the opportunity to train your clinical staff on documentation best practices. Use Medicare Utilization data as a starting point for audits, and be sure to circle back around with physicians on any downcoded charts so they won’t keep making the same mistakes or omissions.
A 97 percent denial rating is a shocking statistic. And WPS-GHA didn’t randomly choose 99285 as a code to review. E&M level creep is real, and whether it’s justified or not, payers are using it as an excuse to look more closely at the codes being billed. When they select your claims for review, be sure you’ve returned requested information, chosen the correct code, and documented sufficiently.
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