Handout 3

Evaluation and Management (E/M) Services Billed to WPS Medicare - Part B
~CERT Error Examples and How to Avoid Them~
Insufficient Documentation
Error Examples
How to prevent this type of error
Billed CPT 99211. Submitted documentation supports the Services billed to Medicare under CPT code 99211 must be only face to face service provided on the billed date of reasonable and necessary for the diagnosis and treatment of service was venipuncture. No additional evaluation or an illness or injury. Furthermore, a face-to-face encounter management service other than the beneficiary notification with a patient consisting of elements of both evaluation and to change current Coumadin dosing is documented. management is required. The evaluation portion is substantiated when the record includes documentation of a Billed CPT 99211 - Office or other outpatient visit for the clinically relevant and necessary exchange of information evaluation and management of an established patient that between provider and patient. The management portion is may not require the presence of a physician, usually, the substantiated when the record demonstrates an influence on presenting problem(s) are minimal, typically, 5 minutes are patient care (ex., medical decision making, patient education, spent performing or supervising these services. Submitted note states, "Draw CBC." This does not support a separately identifiable service from billed venipuncture CPT 99211 should not be used for:
on line 2 of this claim. Insufficient documentation to support service as billed.  Drawing of blood for laboratory analysis or when  Administration of medications when an injection or For more information on this issue and other CERT error findings, visit our WPS Medicare CERT web page articles at: ert_articles.shtml Billed CPT 99232. Submitted documentation includes Refer to CMS Internet-Only Manual, Publication 100-04, hospital progress notes dated including the physician Chapter12, section 30.6.B which states, "if there was no face- assistant's signature and the billing provider signature only to-face encounter between the patient and the physician documenting "agree". No face-to face service was (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPPs UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim." Medicare does not pay for “incident to” services in an inpatient setting. For a split-shared visit, there must be documentation of the face-to-face portion of the E/M encounter between the patient and the physician. Refer to the following resources for more guidance on
these services:
WPS Medicare CERT web page article titled “Inpatient Split/Shared Evaluation and Management (E/M) Services” at: 009_1116_em.shtml Refer to the following sections in the CMS Internet-Only Manual (IOM), Publication 100-04 Chapter 12:  Section 30.6.1(B)(EM level of service - Shared/Split  Section 100.1(.1A) (MD/NPP Services in a Teaching  Section 120.1 (Direct Billing for NPPs in the inpatient Billed CPT 99213. Submitted consists of procedural note All services billed to Medicare must be documented in the for iridectomy. Missing physician progress notes to patient’s medical records and available for review upon support E/M service. Insufficient documentation to support request. Avoid common documentation related denials with these tips for services frequently billed to Medicare Part B at: Billed CPT 99222. Unable to support this claim as reasonable and necessary without supporting documentation. Submitted includes a discharge note, an operative report, a team conference summary, a rehab flow sheet and progress notes unrelated to this date of service. Missing the evaluation and management for this billed claim. Services billed were not rendered
Error Examples
How to prevent this type of error
Billed CPT 99231. CERT informed by billing provider, Billing errors continue to negatively impact CERT error rates. "Upon review of our billing and documentation, we billed To avoid this type of error, we recommend periodic audits of <Dr. X’s> hospital visit in error. There is no documentation your medical record documentation and billing process. If the substantiating this service and billing. Therefore, I have Medicare payment is refunded prior to inclusion in a CERT voided this charge and we will be refunding." Submitted sample, the last iteration of the claim will be reviewed and an includes no documentation for claim from billing provider error will not be assessed for the original incorrect Billed CPT 99238. Submitted documents include a letter from the rendering physician that states "Please be advised that this was billed in error. I have voided the charges." Claim is denied for lack of supporting documentation. Service Provided, but not by Billing Provider
Error Examples
How to prevent this type of error
Billed CPT 99213 - E/M established patient requiring 2
Refer to CMS Internet-Only Manual, Publication 100-02, of 3 key components (expanded history and exam, and low complexity medical decision making) was billed under the physicians NPI. This service is being billed states in part "that there must have been a direct, personal, "Incident To" as the documentation for this date of professional service furnished by the physician to initiate the service supports the service was performed by a nurse course of treatment of which the service being performed by practitioner. The note shows this as a follow-up visit for the non-physician practitioner is an incidental part, and there Fibromyalgia/Chronic Fatigue/Right Lower Extremity must be subsequent services by the physician of a frequency Pain and to assess the patient after starting medication. that reflects the physician's continuing active participation in The handwritten notes indicate previous visits with the and management of the course of treatment." These reason for the visit documented and a note for a requirements must be met and documented in the medical subsequent visit for f/u start Savella. The record for Medicare payment to be made for these services. documentation does not indicate any physician oversight or previous visits by the physician initiating the course of treatment. Based on the documentation, it seems to be a follow-up visit with the NP who started the patient on this medication previously. 31 – Service Incorrectly Coded
Error Examples
How to avoid this type of error
E/M Services Coded to Lower Level by CERT Reviewer
Documentation for Evaluation and Management (E/M) services must support the level of service billed and the Billed CPT 99204 requires 3 of 3 key components
medical necessity of the level. A self-audit is an excellent way (Comprehensive history and exam, and moderate for a physician practice to ascertain if any problem areas exist complexity medical decision making). Documentation
which may warrant further education or corrective actions. supports code change from 99204 to 99201 with
General Tips to consider when performing a self-audit of
expanded problem focused history, problem focused exam, E/M Services:
and moderate complexity medical decision making per  Medical necessity is the overall criterion for payment in addition to the specific technical requirements of a CPT code. Billed CPT 99213 requires two of these three key
 It is not appropriate to bill a higher level of E/M
components; EPF history and exam; medical decision service when a lower level of service is
making of low complexity. Documentation supports re
warranted.
code from 99213 to 99212 which requires two of these
 The volume of documentation should not be used to three key components: Problem focused history and exam; medical decision making of straightforward complexity. The  Documentation must support the level of service documentation submitted supports expanded problem focused history; Problem focused exam and medical  In order to maintain an accurate record, document decision making of straightforward complexity. during or shortly after rendering the service. Billed CPT 99214. Submitted documentation supports
Visit the WPS Medicare Evaluation and Management web
down code from 99214 to 99213 with EPF history, no
exam, and decision making of low complexity. None of the required components of 99214 were met. Noted prolonged types/evalandmngmnt.shtml for articles, CMS resources, and visit with patient re: return to work. Time not recorded. Has Frequently Asked Questions (FAQs) to assist you in the 18 medical problems, only 2 addressed. Undated problem proper documentation and billing of these services. list submitted, with 18 problems. Letter to <Dr. X> that is referenced in progress note gives brief summary of Our WPS Medicare Training web page:
grams/ is also a great resource for upcoming educational Billed CPT 99215 requires at least 2 of these 3 key
teleconferences or in-person seminars in your area! components: a comprehensive history; a comprehensive
examination; medical decision making of high complexity.
Submitted documentation meets expanded problem
focused history, comprehensive exam and low MDM.
There is no chief complaint documented; [there are 3
chronic conditions listed in the HPI]; ROS is complete;
Under Assessment & Treatment Plan Physician documents
the 3 chronic conditions noting "mild (L)HP, HTN- stable,
Hyperlipid- ck labs" Documentation supports down
code to 99213.
Billed CPT 99223 requires 3 of the following 3
components: Comprehensive History, Comprehensive
Exam, and High Medical Decision Making. Documentation
supports down code to 99221-25 with Detailed History,
Detailed Exam, and Moderate Medical Decision Making.
Billed CPT 99233. Documentation supports code
change from 99233 to 99232 meeting 2 of 3 required
components Detailed history, expanded problem focused
exam, and moderate complexity medical decision making.
Billed CPT 99284 requires 3 of 3 key components
(Detailed history and exam, and moderate medical decision
making). Documentation supports code change to
99283 with Comprehensive history, expanded problem
focused exam, and moderate medical decision making per
1995 and 1997 E/M guidelines.
Billed CPT 99308. Poorly legible, brief, documentation
supports down code from billed 99308-GV (Subsequent
NF visit requires 2:3 key components; Expanded problem
focused history, expanded problem focused exam, low
complexity medical decision making - MD not under
Hospice payment), to 99307-GV with Problem focused
history, no exam, and straightforward medical decision
making.
E/M Services Coded to a Higher Level by the CERT
Documentation for Evaluation and Management (E/M) Reviewer
services must support the level of service billed and the medical necessity of the level. Providers should bill the Billed CPT 99212 requires 2 of 3 key components problem
appropriate level of E/M service based on what was focused history and exam, and straightforward medical performed and documented as medically necessary in the decision making). Documentation submitted supports
patient’s record. These “under coded” services have the up code to 99214 with detailed history and exam, and
same negative impact on CERT error rates as “over coded” straightforward medical decision making per 1995 and 1997 E/M guidelines. By 1995 guidelines, it scored detailed history, comprehensive exam, and straightforward A self-audit is an excellent way for a physician practice to medical decision making but by 1997 guidelines, it scored ascertain if any problem areas exist which may warrant further detailed history, detailed exam, and straightforward medical decision making. This is a post op visit following General Tips to consider when performing a self-audit of
PTA (Percutaneous Angioplasty), patient still c/o E/M Services:
swelling/edema, leg cramps and dizziness. Will up code  Medical necessity is the overall criterion for payment based on the presenting problems and the in addition to the specific technical requirements of a  It is not appropriate to bill a lower level of E/M
Billed CPT 99213. Documentation supports code
service when a higher level of service is
change from 99213 to 99214 meeting 2 of 3 required
documented and warranted.
components Expanded Problem Focused History,  The volume of documentation should not be used to Comprehensive Exam, and Moderate Complexity Medical  Documentation must support the level of service Billed CPT 99231 requires 2 of 3 components of problem
 In order to maintain an accurate record, document focused history, problem focused exam, and during or shortly after rendering the service. straightforward/low complexity medical decision making.
The documentation reviewed supports an up code to
Visit the WPS Medicare Evaluation and Management web
CPT 99232 with expanded problem focused history,
expanded problem focused exam, and moderate types/evalandmngmnt.shtml for articles, CMS resources, and Frequently Asked Questions (FAQs) to assist you in the proper documentation and billing of these services. Billed CPT 99281 requires 3 out of 3 key components
problem focused history, problem focused exam, and
Our WPS Medicare Training web page:
straightforward medical decision making. Documentation
supports up code to 99282 with expanded problem
grams/ is also a great resource for upcoming educational focused history using 1995 and 1997 E/M guidelines, teleconferences or in-person seminars in your area! Detailed Exam using 1995 E/M guidelines and Problem Focused Exam using 1997 E/M guidelines (5 bullets/ 6 body system), Moderate Complexity MDM (worsening established problem, RX medication given). Documentation supports that the presenting problem are low to moderate severity.

Source: http://wpsmedicare.com/j5macpartb/training/on_demand/_files/em-handout-3.pdf