Documentation for these services may include, but not limited to:
- Progress notes for the date(s) of service in question
- Written/telephone physician orders
- An example of the provider’s signature
- If the signature on the documentation supporting the service is missing or illegible, please submit an attestation statement from the performing provider verifying that they personally performed the service(s).
- The procedure report or other applicable documentation if the E/M was billed with the 25 modifier, indicating it was separately identifiable from the procedure
- Any other type of documentation to substantiate the medical necessity for the particular service(s)
CPT Code 99213 (All Specialties) –Review
Established Patient Office or Other Outpatient Visit services are a focus area for the FY 2010 Medical Review Strategy. Analysis of claims in the May 2009 sample period reveals there were 217 CERT errors. Of this number, 135 (62.21%) were for BETOS categories primarily reporting Evaluation and Management (E/M) procedure codes. Approximately 82% of the CERT errors for E/M codes were for incorrectly coded services. BETOS Category M1B – Established Patient Office or Other Outpatient Visit services had the second highest number of errors in comparison to the other E/M BETOS categories. Review of claims in the November 2009 sample period for BETOS Category M1B-Established Office Visits for the time frame of 04/01/2008 through 03/31/2009, revealed that established office visits accounted for 40% of the E/M CERT errors. Incorrectly coded services made up approximately 68% of the errors in this BETOS Category. CPT code 99213 comprised 21% of the incorrectly coded errors.
By contractual obligation with the Centers for Medicare and Medicaid Services (CMS), WPS routinely performs medical review/audits (probes) of services or select providers. Due to the reasons described above, widespread Service-Specific Prepayment Probe Reviews will be conducted on Current Procedural Terminology (CPT)® Code 99213 to identify educational opportunities within the Jurisdiction. The claims samples for these Service-Specific Prepayment Probe claims will be obtained from Wisconsin, Illinois, Michigan, and Minnesota for all specialties. Widespread Service-Specific Probes are conducted to validate potential systemic problems with billing, utilization, and/or documentation of a specific service. These reviews involve a random sample of 100 claims submitted from a cross-section of all providers or suppliers in a defined group who bill the particular item or service in question. The medical records are requested for the sample and are reviewed.
An Additional Documentation Request (ADR) Letter will be sent requesting medical records for services of CPT code 99213 (Established Patient Office or Other Outpatient Visit) billed on claims selected for these probes. If an ADR is received, it is the billing provider’s responsibility to provide the required pre-existing documentation necessary to conduct a medical record review. As part of the audit process, WPS utilizes the documentation in the medical records to make review determinations for all services billed on the claims identified in the ADR request. Providers must submit ALL the documentation that is necessary to support the medical necessity for each billed service and to substantiate the appropriate use of each billed procedure code. This may require you to contact other providers, agencies, and/or facilities to obtain the requested medical records.
