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Code overutilization

Rimma Posted Wed 31st of August, 2011 18:20:34 PM

Our practice has received a letter saying that we have overutilized CPT code 99204 as compared to other physicians. We are asked to review our internal controls and determine to what extent we are at risk for receiving overpayment. We have EMR in the office so everything is well documented. in addition, all cases are routinely done with anesthesia, so additional risk questions related to procedures are always documented as well. how should we proceed?

SuperCoder Answered Thu 01st of September, 2011 06:47:46 AM

If you received letter from payer, then there is no need to worry. Just Audit your internal documentation and reporting.

If letter is from Medicare or any of the fiscal intermediary , then you need proper audit system in place to adhere with medicare compliance guideline. After implemenatation of ARRA (americal recovery and reconsilation act), Audit is a remarkable issue throughout the country.

Hope this can help. please revert if we can assist you more.

SuperCoder Answered Thu 01st of September, 2011 07:09:47 AM

Codes that Medicare and Medicaid have identified for special scrutiny include:

99214 (E&M code, level 4 -- established patient)
99204 (E&M code, level 4 -- new patient)
99205 (E&M code, level 5 -- new patient)

View your billing patterns as a bell curve. You should bill more 99203 (Evaluation and Management [E&M] code level 3 ­ new patient) codes and fewer 99201 (E&M code level 1 ­ new patient) and 99205 (E&M code level 5 new patient) codes.

1. Check mostly the ones with modifier 25 or 57. There is possibility in many cases, the MDM went high even though for the same you have already billed a procedure along with. Error of double-dipping has higher chances.

2. Categorize the frequency of specific type of visits that you think should go with Level 4 and check the PE and MDM components lapses in those reports which normally doesn't go with 99204.

3. Need to make complete audits or you can use any Audit Tools to filter 99204 claims with some lapses.

Rimma Posted Thu 01st of September, 2011 21:27:16 PM

code utilization - so we should audit outselves and wait or report back to the fiscal intermediary?

SuperCoder Answered Thu 01st of September, 2011 22:05:28 PM

Submit your Internal Audits asap, that will help improve the status of denials and overall image regarding compliance issues. Need to have initial talks with Insurance regarding your Audits and Audit criteria and to know what is the preference of the Insurance in this regard, convince them that you are going to implement this and submit your report ASAP. Submit your audits after necessary adjustments.

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