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July 30, 2013

CPT Code 99310: Prepayment Edit Review Findings

Background:

Based on CGS data analysis and findings in our review of claims for CPT code 99310 earlier this year, CGS initiated a prepayment medical review of claims documentation a summary of our findings is provided below.

CPT code 99310 "requires at least 2 of these 3 key components: a comprehensive interval history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes at the bedside and on the patient's facility floor or unit."

Findings:

The prepayment review focused on review of documentation to support the level of care as billed. The following list represents the prevailing errors seen by Medical Review:

  1. Denials for non-receipt of documentation requested
    1. No documentation received
    2. Only the letter is returned with no comment
    3. No facility notes provided to support the visits; only provider letters are received
  2. Denials for lack of signatures:
    1. If a note is unsigned or the signature is illegible, we will contact the provider to obtain an attestation. However, if no attestation, signature log, or signed note is received, we will deny the service.

CGS continues to see errors due to inadequate provider signatures on documentation submitted for medical review. Documentation must support the medical necessity of the services provided, but without the proper signature of the rendering/billing provider, records cannot be validated and services will be denied. The CMS Program Integrity Manual (Pub 100-08, chapter 3, section 3.3.2.4) states: "Medicare requires a legible identifier for services provided/ordered. The method used shall be handwritten or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes.”

  1. Illegible Documentation
    1. All entries must be legible to another reader in order for a meaningful review to be conducted. CGS recommends that only Joint Commission: Accreditation, Health Care, Certification (JCAHO) approved abbreviations be used to prevent patient care errors and allow for proper review by subsequent readers. Illegible notes will not be used in determining medical necessity of a claim.
  2. Provider performing the services is not the billing provider
    1. Documentation submitted indicates the service performed was not the billing Physician/NPP. Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6.13External PDF:

      - 'Incident to' billing is not permitted in facility settings

      - Split/shared visits are not permitted in a Skilled Nursing Facility/Nursing Facility setting

  3. Documentation submitted did not support the level of care billed
     Medicare allows only the medically necessary portion of a visit even if a complete note is generated. Only the necessary services for the patient at the time of the visit can be considered to determine the level of an Evaluation & Management (E/M) service. Refer to SSA 1862(a)(1)(A) and the CMS Medicare Claims Processing Manual, chapter 12, sections 30.6.1 through 30.6.13External PDF.
  • Patient claim histories indicate frequent visits by same provider and/or multiple providers within the same group without documented change in beneficiary clinical status
  • Medical decision making was, in many cases, a statement such as “continue current treatment”
  • Cloned documentation

Based on our review findings to date, we have identified the need for ongoing education. Therefore, the prepayment review will continue until further notice.

Resources:

Please review the following sources for guidance regarding documentation guidelines for E/M services:

CGS also recommends reviewing your medical records and conducting self-audits to determine documentation deficiencies in relation to the potential errors identified above.

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