In the May 2006 Comprehensive Error Rate Testing (CERT) report the CERT contractor, AdvanceMed, reported a 13.5 % paid claims error rate for hospital visit - subsequent, codes 99217, 99231 ' 99236, 99238 ' 99239, and 99356 - 99357, for all carriers in the nation. CERT projected the national dollars paid incorrectly amount to be $619,744,898.00.
The latest data available for South Carolina comes from the November 2005 report with an error rate of 11.9%.
For the state of South Carolina, internal medicine physicians were responsible for the majority of the errors, followed by neurologists and cardiologists. From the November 2005 data, numerous exam and management codes were reduced one level but the majority of the errors were because there was no documentation to support the services billed.
When AdvanceMed requests documentation for an inpatient visit, of any kind, it will be necessary for the provider's office to request the documentation from the hospital where the patient was admitted. AdvanceMed has no knowledge of the hospital the patient was admitted to and would request records from the billing physician directly. Some of the reasons for not returning the documentation included:
'Patient deceased, records in storage'.
'This is everything we have on this patient ' we have not seen patient since 07/13/04'.
'This patient was not at our facility on 03/13/2004'.
The CERT contractor found these reasons unacceptable.
Some providers have submitted billing sheets, patient information sheets, echocardiogram reports, chest x-ray reports or charge slips instead of sending the treating physician's inpatient progress notes. Since these documents did not support the services billed to Palmetto GBA, refunds were requested for those services.
All documentation to support services billed should be sent to AdvanceMed or the CERT documentation contractor
immediately upon request to avoid an overpayment. We suggest that you designate one person in your office to handle all requests from AdvanceMed.
© CPT ' 2006 Appendix C contains clinical examples of all levels of Exam and Management codes. Additional information on correctly coding evaluation and management services can also be found on our Web site at
www.PalmettoGBA.com. Select Learning and Education from the drop down box. Then, choose workshop handouts on the left hand side of the page. And finally, choose 2005 Medicare Part B Evaluation and Management Workshop Handout. You can also find an on line workshop regarding subsequent hospital visits on our Web site at the home page under on-line learning.
Additional information about the CERT program can be found at
http://www.cms.gov/cert.