In the May 2006 Comprehensive Error Rate Testing (CERT) report, the CERT contractor, AdvanceMed, reported a 20.3% paid claims error rate for initial hospital visit, CPT codes
99221 ' 99223 , for all carriers in the nation. CERT projected the national dollars paid incorrectly amount to be $233,059,169.00.
The latest data available for South Carolina comes from the November 2005 report with an error rate of 17.4%.
For the state of South Carolina, internal medicine and family practice physicians were responsible for the majority of the errors, according to the November 2005 report. From the November 2005 data, numerous exam and management codes were reduced. Several of the claims for procedure code
99223 were down coded to
99221 . These reductions were necessary because
all three of the key components required for the code were not met. The three required components are history, exam and medical decision-making. AdvanceMed found that the history and exam components were more likely to be below the required level than the medical decision making component.
© 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.'
All errors found by the CERT contractor result in overpayments by Palmetto GBA to recoup funds paid to the provider in error. All documentation to support services billed should be sent to AdvanceMed or the CERT documentation contractor
immediately upon request to avoid an overpayment.
Additional information about the CERT program can be found at
http://www.cms.gov/cert.