CPT codes, descriptions, and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyrighted by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement.
CERT Spotlight: Consultations
On the November 2005 Comprehensive Error Rate Testing (CERT) report the CERT contractor, AdvanceMed, reported a 10.2% paid claims error rate for consultation services billed by physicians in South Carolina. The error rate results in $3,950,029.00 projected dollars incorrectly paid.
Analysis of the claims paid in error resulted in the following information.
The specialty of gastroenterology had the most claims paid in error, followed by surgery, otolaryngology, neurology, psychology and family practice.
Four claims were reduced by at least one procedure code level: Consultation codes 99241 through 99255 require all three of the key components which differ based on the specific procedure code. In order to get paid for 99243, for example, the provider must document a detailed history, a detailed examination and medical decision making of low complexity. All of the reduced claims did not meet the requirement for each component. Meeting two components out of the three will result in the claim being reduced by AdvanceMed.
Four claims had code changes from consultation codes to various other exam and management codes depending on the situation and the documentation submitted. These code changes were because the letter back to the requesting physician was not included in the patient's record. Per © CPT-2006 'The consultant's opinion and any services that were ordered or performed must be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source'.
One claim had a code change because the record identified that the physician called in for the consultation was managing the patient care. Per © CPT-2006 'If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient's condition(s), the appropriate evaluation and management services code for the site of service should be reported.
Two claims had all the money recouped because there was no documentation to support the service was rendered. On both of these claims AdvanceMed received lab work and other diagnostic testing results for the claims but did not receive the required documentation from the billing provider. It is the billing provider's responsibility to provide AdvanceMed with documentation to support the service.
One claim was increased two levels from 99241 to 99243.