01/29/2016

Medicare Prepayment Audits Continue

National Government Services (NGS) continues conducting service-specific prepay review of home visits, CPT 99348, 99349, and 99350, when performed by podiatrists in downstate and Queens County, NY.  They have not provided an end date for this review.

The primary focus of the audits is to identify common billing errors, develop educational efforts, and prevent improper payments.  Providers are receiving ADS letters asking for documentation to support the service billed. Providers are encouraged to respond with the requested documentation in a timely manner to expedite adjudication of these claims. It is our understanding these claims could take up to 60 days to adjudicate.

Review Findings
The following results are based upon the published review for JK Part B claims submitted that contained CPT codes 99348-99350.

• 1518 total claims billed; 1214 (79.9%) were reduced or denied
• 1537 total services billed; 1231 (80.9%) were reduced or denied

Services were reduced or denied for the following reasons:

• Incomplete and/or illegible documentation;
• Billing of a visit in lieu of the actual podiatric service that was performed (e.g., routine foot care, debridement of nails, etc.);
• Visits were reported with modifier 25 indicating the E&M was a significant, separately identifiable service; however, the documentation lacked data to support use of the 25 modifier;
• Duplicate services/claims;
• Missing physician’s signature on submitted documentation;
• The documentation submitted did not support the required key components of the CPT code as notated in the CPT Manual;
• Beneficiary name and/or date of service was missing/omitted on the submitted documentation;
• No response to the documentation request; and/or
• Place of service 16 (temporary lodging) was being billed for visits/services rendered in the patient’s home.

The CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 states: “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

Billing Recommendations
CPT codes 99341-99350, home services codes, are used to report E&M services furnished to a patient residing in his or her own private residence (e.g., private home, apartment, town home) and not residing in any type of congregate/shared facility living arrangement including assisted living facilities and group homes. The home services codes apply only to the specific two-digit POS 12 (Home). Home services codes may not be used for billing E&M services provided in settings other than in the private residence of an individual as described above.

Home services codes 99341-99350 are paid when they are billed to report evaluation and management services provided in a private residence. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home.

Under the home health benefit the beneficiary must be confined to the home for services to be covered. For home services provided by a physician using these codes, the beneficiary does not need to be confined to the home. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit.

When documenting E&M services:

• Be sure to include the physician’s signature; the full name and title is needed, no initials
• Include relevant test results
• Include pertinent physician orders
• Include progress note in support of the services billed
• Documentation must be legible

In addition, medical record documentation must meet the following criteria:

• Clearly identify the patient, date of service, and who performed the service;
• Accurately report all pertinent facts, findings, and observations;
• Include appropriate diagnosis for the service provided; and
• Documentation must have a hand written or an electronic signature. Stamp signatures are not acceptable.

The National Government Services Provider Outreach and Education Department can assist with Medicare coverage, medical policy, medical necessity, and documentation questions through the JK Provider Contact Center at 866-837-0241.