WPS, the Medicare administrative contractor for Indiana, advised that Comprehensive Error Rate Testing (CERT) indicates the following three CPT codes are incorrectly coded at a rate of at least 44 percent. The incorrect use of these codes could result in an adjustment of your claims in an overpayment or underpayment. The three codes are:
- 99215 - Office or other outpatient visit for the evaluation and management of an established patient
- 99222 and 99223 - Initial hospital care, per day, for the evaluation and management of a patient
If you use these codes for billing, you are encouraged to perform a self-audit of your billing and documentation process to determine whether billing and documentation in the medical record support medical necessity and the level of service you are billing.
Find more information and examples of incorrect billing here.
Denial of related claims
Beginning Sept. 8, the Centers for Medicare & Medicaid Services gave Medicare contractors the discretion to deny claims they considered “related” claims. If documentation associated with one claim can be used to validate another claim, those claims may be considered “related."
WPS need not request additional documentation for a “related” claim before denying it. Appeals for both claims will be handled separately. If lack of medical necessity is determined, WPS or Zone Program Integrity Contractors (ZPICs) can conduct post-payment audits and can deny a claim automatically after a denial by CGI, Indiana’s recovery auditor contractor (RAC).
The “related” claims pertain to improper admissions. “CMS does not want a patient to be admitted to a hospital for services if those services can be performed on an outpatient basis,” said Jeri Biedenkopf, R.N., ISMA practice advisor.
CMS Transmittal 534 states:
The MAC performs post-payment review/recoupment of the admitting physician's and /or surgeon's Part B services. For services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services could have been provided as outpatient or observation), the MAC reviews the hospital record and if the physician service was reasonable and necessary the service will be recoded to the appropriate outpatient evaluation and management service. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, postpayment recoupment will occur for the performing physician’s Part B service.
To learn more, see Transmittal 534 here.