License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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July 19, 2012

Results of Ohio Progressive Corrective Action (PCA) For Emergency Department Services (new and established)

New and Established Emergency Department Services were identified as an area of focus for our Progressive Corrective Action post payment review in the state of Ohio.

Reviews were conducted among the top billing providers and provider groups of the CPT codes for New and Established Emergency Room visits.

A total of 160 claims were reviewed by our clinicians (60 claims were denied due to non-response) and those resulted in an error rate of 62%.

Common findings resulting in denial or reduction of the service billed include:

Documentation does not support high complexity decision making; therefore did not support the level of service billed.
1. Claims reduced/allowed at moderate to low complexity decision making as perform by provider.
No documentation of services performed by billing provider. Documentation indicates Physician Assistant provided the service.

Through our review, we have identified the need for ongoing education. Please review the following sources:

Medicare Claims Processing Manual
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Chapter 12 of the Claims Processing Manual includes guidelines for many topics that involve evaluation and management services. Please peruse the entire table of contents and chapter.
The following topics were, specifically, used in the educational material provided on some of our recent probes.
- 30.6 - Evaluation and Management Service Codes - General (Codes 99201 - 99499)
- 30.6.1 – Selection of Level of Evaluation and Management Service
- 30.6.11 – Emergency Department Visits (Codes 99281 - 99288)

Documentation Guidelines for Evaluation and Management Services

E/M Coding: Volume of Documentation versus Medical Necessity
http://www.cgsmedicare.com/partb/mr/articles/em_volume.html

Medical Necessity for Evaluation and Management Services
http://www.cgsmedicare.com/partb/cert/articles/045.html

Documentation Checklist
http://www.cgsmedicare.com/partb/mr/pdf/99285.pdf

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Results of Ohio Progressive Corrective Action (PCA) For Emergency Department Services (new and established)

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