Evaluation Management - Prepayment review for CPT codes 99223 and 99233


First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high comprehensive error rate testing (CERT) error rates for evaluation and management services pertaining to Current Procedural Terminology®(CPT®) codes 99223(initial hospital visit) and 99233(subsequent hospital visit). The CERT November 2014 forecasting report indicates a projected error rate of 39.8 percent for CPT®code 99223 and a projected error rate of 34.4 perc for CPT®code 99233. The data indicates that the specialty of internal medicine is the primary contributor to the CERT error rate: internal medicine error rates are currently trending at 36.6 percent for CPT®code 99233 and 33.3 percent for CPT®code 99223.

Documentation requirements

The American Medical Association (AMA) CPT®manual defines code 99223as follows:
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:

 A comprehensive history;
 A comprehensive examination; and
 Medical decision making of high complexity
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the problem(s) requiring an admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital unit.

The AMA CPT®manual defines code 99233 as follows:
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:
 A detailed interval history ;
 A detailed examination;
 Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs.

Usually, the patient is unstable or has developed a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital unit.

First Coast and the Centers for Medicare & Medicaid Service (CMS) offer multiple resources addressing the documentation guidelines for E/M service levels at:

 First Coast’s Evaluation and Management (E/M) services page, offering links to tools, FAQs, online learning, and additional resources.
 CMS Internet-only manual (IOM) guidelines addressing multiple types and settings pertaining to E/M services.

First Coast actions
In response to the high percentage of error rates and the continual risks of improper payments associated with hospital care visits billed by internal medicine specialists, First Coast will be implementing a prepayment medical review audit for CPT®codes 99223 and 99233 billed by internal medicine specialty. The new audit will be based on a predetermined percentage of claims in an effort to reduce the error rates for these hospital services. The audit will be implemented effective October 21, 2014.


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