Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

WPS Medicare to Review Subsequent Hospital Care Claims

WPS Medicare, Indiana’s Medicare Administrative Contractor (MAC), recently announced a Widespread Prepayment Service Specific Probe Review on a Subsequent Hospital Care evaluation and management (E&M) code for Indiana providers.

The review will be limited to Current Procedural Terminology (CPT)* code 99233 and will include a random sample of 100 claims submitted from a cross section of Indiana providers who bill the code. More than 31,800 providers are eligible.

Selected providers will receive an additional documentation request letter (ADR) requesting medical records supporting all services on claims that are chosen, not just the E&M code. Providers have 30 days from receipt of the ADR letter to comply or face possible denial, or reduction, of payment for the service. Review determinations will be made based on the documentation provided.

E&M codes have been under fire recently after reports in 2012 by the Center for Public Integrity and the Office of Inspector General found that the levels of patient visits submitted to Medicare, along with payments for those services, have risen sharply in the past decade.

Additionally, WPS Medicare has consistently reported high levels of coding errors for several E&M codes as discovered during their Comprehensive Error Rate Testing (CERT). In October 2012, they reported erroneous coding rates of at least 47% for three codes: 99310, 99223, and 99233. And in April 2013, they reported that Subsequent Hospital Visits, the target of the Prepayment Probe, had the highest error rate in a sample review of Calendar Year 2011 claims.

In addition to targeting specific services, MACs may also target for audit specific providers whose E&M levels are higher than average. According to Stacy Harper, JD, MHSA, CPC, in a January article on the American Academy of Professional Coders (AAPC) website, comparing E&M levels to national averages in a provider’s same specialty is one way to minimize audit risk.

Annual utilization data for the top procedures is available on the Centers for Medicare and Medicaid Services (CMS) website. Using these files, providers can extrapolate a bell curve of office, outpatient, or inpatient visits and then compare their practice’s percentages. The AAPC also has an E&M Utilization Benchmarking Tool available on their website that allows providers to compare office visits (new and established) by specialty with Medicare data.

While providers shouldn’t change their coding to fit national averages, once benchmarks are applied, any areas that are significantly different than the averages might provide a place to begin internal auditing and review.

Another way to minimize audit risk and ensure providers successfully pass an audit is to choose the correct level of E&M codes and supply the proper documentation. CMS’s “Evaluation and Management Services Guide” will provide a place to start in that process.

*Codes Copyrighted By American Medical Association

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

© Copyright 2020