Annually, the Centers for Medicare and Medicaid Services monitor the accuracy of Fee-For-Service (FFS) payments. CMS contractors use the Comprehensive Error Rate Testing (CERT) program to determine which services are experiencing high error rates. One particular topic recently highlighted was the incorrect use of evaluation and management code 99211.

Per the 2009 Current Procedural Terminology (CPT) manual, 99211 is  "Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services." Below are examples of the CERT reviewer comments where insufficient documentation resulted in refunds from the providers:

• Documentation reviewed includes no supporting documentation or presenting problem/symptom or medical evaluation provided. Documentation supports prothrombin anticoagulation check (CPT 85610) which is found billed separately for same date of service.
• Note from provider states, "Patient had labs done only. Did not see the doctor." Documentation consists of protime results and instructions on drug dosage.
• Flow sheet received contains only the "results of the test, continue same, and check in 2 weeks." There is insufficient documentation to indicate that there was any E/M service performed. It would appear that the encounter was exclusively for the purpose of venipuncture.
• There is no documentation of a face to face, separately identifiable E/M service to support billed CPT 99211. There are no circumstances documented to demonstrate a need for clinical evaluation and management. Submitted is an "Anticoagulant Flow Sheet" with date, INR results, current dose, new dose, ordered by, notified by, next check, and comments.
• Submitted documentation is insufficient to support minimal office visit. Received from follow up is a progress note indicating patient was notified of lab results.
• Submitted are physician records stating "Here for his first Synovisc injection." Arthrocentesis and synovisc injection codes also billed this claim for same date of service. Noted use of modifier 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), however, submitted documentation does not support modifier code; documentation states "detailed note is in the chart from his last visit."

As with all E&M codes, 99211 requires a face to face encounter consisting of elements of evaluation and management. When the record contains documentation of a clinically relevant exchange of information, the evaluation is substantiated. The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.). CPT 99211 should not be used for:

• Phone calls to patients
• Drawing of blood for laboratory analysis or when performing other diagnostic tests
• Administration of medications when an injection or infusion code is submitted separately

Non-physician providers may perform 99211 services if their state licensing permits the conduct of patient care. These can be billed to Medicare as incident-to services when there is a physician service to which the non-physician providers' services relate.

Proper Billing of the Same Surgical Procedure Code Multiple Times on the Same Day

Modifier 76 from the 2009 Common Procedural Terminology manual is used to designate a service that is a "Repeat Procedure or Service by Same Physician". However, some Medicare contractors do not recognize Modifier 76 for surgery codes.

If your contractor does not accept 76 for surgical codes, and you need to properly report the performance of multiple instances of the same surgical procedure code on the same day by the same provider, first review the description of the procedure code. If the surgery is one that may be performed more than one time on the same day, you can bill multiple units if your contractor's Medicare's claims processing system will allow it.

If you don't know if the surgery code can be quantity billed, call your contractor's Medicare Customer Service and ask, "Will your claims processing system allow me to quantity bill code XXXXX?" If the code cannot be quantity billed, you will need to bill each surgery on a separate line on the same claim and provide narrative information for each line, or at claim level, that indicates the number of times the surgical procedure was performed. For example, "code XXXXX performed a total of three times on MM/DD/YYYY."

If you receive duplicate denials for a surgical procedure performed multiple times on the same day by the same provider for the same beneficiary, request a Redetermination and submit supporting documentation to justify the services.

New Advance Beneficiary Notice Replaces Three Forms

Effective March 1, 2009, providers must begin using the revised "Advance Beneficiary Notice of Noncoverage" (ABN) (CMS-R-131). The revised ABN satisfies both mandatory and voluntary notice functions and replaces the ABN-G (CMS-R0131-G), ABN-L (CMS-R-131-L), and Notice of Exclusion from Medicare Benefits (NEMB).

Key features of the new form include a mandatory field for cost estimates of the items/services at issue  and a new beneficiary option, under which an individual may choose to receive an item/service, and pay for it out-of-pocket, rather than have a claim submitted to Medicare.

Medicare Makes Expanded Benefits Brochure Available

The Expanded Benefits Brochure is now available in downloadable format. This tri-fold provides health care professionals with an overview of Medicare's coverage of three preventive services: the initial preventive physical examination (IPPE), also known as the "Welcome to Medicare Physical Exam", ultrasound screening for abdominal aortic aneurysms, and cardiovascular screening blood tests.

Dr. Carter's Corner
Darren Carter, MD, founder and President of Provistas, has a personal commitment to alleviating uncertainties in the health compliance environment. He has authored dozens of articles, presents to professional and hospital associations, serves on several editorial boards, and provides consulting and expert witness testimony.