Heads Up! Medicare Ramps for Prepayment Audits for specific codes
99205 - Office or other outpatient visit for the evaluation and management (E&M) of an initial patient billed by physician specialty 11 (Internal Medicine)
99215 - Office or other outpatient visit for the E&M of an established patient billed by physician specialty 83 (Hematology/Oncology)
99223 - Initial hospital inpatient billed by physician specialty 02 (General Surgery)
99233 - Subsequent hospital inpatient visit billed by physician specialties 06 or 10 (Cardiology or Gastroenterology)
97001-97799/G0283 - Physical therapy services billed by physician specialty 08 (Family Practice)
98941 - Chiropractic Manipulative Treatment (CMT); spinal, three to four regions
99354-99357 - Prolonged services requiring direct patient contact beyond the usual service
If your practice is selected you will be notified that a “probe review” is being conducted and you will receive a request for medical documentation or “additional development request” for the claims in question. National Government Services provides that “[a]fter review of the documentation is completed, providers receive notification of the results of the probe review. A provider specific error rate is calculated by the number of claims paid in error, dollar amounts improperly paid, and past billing history.”
The best way to prepare for a prepayment review is to self-audit and (recommended) bring in an outside consultant to perform an audit of your documentation and billing practices to ensure you are meeting Medicare guidelines. Just because you have not been audited yet, or you "have been billing the same way without incident for 25 years" does not mean you are billing properly or documenting properly. Just as you may tell your patients, better to take preventative measures...
Looking for a referral to a coding expert? Let me know.
Contact Jennifer at Jennifer@Kirschenbaumesq.com or at (516) 747-6700 x. 302.
at a residency/fellowship program?
Contact Jennifer directly at (516) 747-6700 x. 302 or at Jennifer@Kirschenbaumesq.com