Pre-Payment Audits Expand to Include CPT® 99214

As you are aware, National Government Services (NGS), our local Medicare Administrative Contractor, reviews data provided from CMS to identify coding and claim submission patterns that may indicate a propensity for an above average error rate.

CERT, the Comprehensive Error Rate Testing program, was established by CMS to research and calculate the Medicare Fee-For-Service improper payment rate based on reviews of paid claims. Recently, CERT has projected that CPT® 99214 may be responsible for one of the highest error rates among Evaluation and Management codes.

Consequently, NGS has added CPT® 99214 to its list of E&M services subject to pre-payment audit, effective immediately. This code represents office or out-patient services for your established patients, and the documentation requirements for CPT® 99214 include either a detailed history or examination and medical decision making of moderate complexity.

CPT® 99214 joins other E&M codes that were previously established as having a high error rate and which have been on a random pre-payment audit since 2014. These are CPT® 99215 in the out-patient setting and both 99223 and 99233 in the in-patient setting. These codes continue to demonstrate an error rate above 60% and often much higher.

The Compliance Department will be reaching out to you for either pre-submission review or post-adjudication results of your medical record requests. This will provide real-time feedback on how our local Medicare carrier assesses your documentation.

As always, please remember that medical necessity is the driver for the amount and detail of the documentation and ultimately the level of service assigned for a given service. As published in the CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1:

The 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 level of service is billed. Documentation should support the level of service reported. Providers should select the code for the service based upon the content of the service. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

Click here for a link to the NGS article regarding CPT® 99214.