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Why is Medicare requesting notes for code 99204?

Marina Posted Mon 11th of February, 2013 22:23:51 PM

We have always billed Medicare using code 99204 and they have never once requested notes. Recently, our office has billed using this code and Medicare is kicking it back saying additional supporting documentaion is needed. Is this something new for 2013 that we are not aware of?

SuperCoder Answered Tue 12th of February, 2013 19:04:21 PM

This could be true depending what state you are in. Highmark in New Jersey sent out a notice that they would be requiring pre-payment review of all 99204 and 99205s. Even commercial carriers do this from time to time to motivate providers to bolster their supporting documentation. In the case of Highmark, they found deficiencies in the comprehensive history and exam areas on these higher level new patient codes. It is somewhat surprising that they did not mention decision making on the 99205s as that can be difficult to master. The history and physical exam issues are likely more of a housekeeping variety.

You could also be hearing about what has been dubbed "ask first, pay later." New legislation requires CMS to change their methodology of paying claims first and doing reviews later — also called "pay and chase" — and adopt billing software designed with predictive modeling capabilities. So there is the answer to whether they can do that. How they do it? It has to be manual, so you are in the hands of auditors. As to the local issue, if it applies in your state it is likely limited in duration — it must be expensive and these types of reviews are typically short-lived, unless the results and subsequent downgrading of claims outweigh the cost.

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