Inpatient Facility Coding & Compliance Alert

Question: We billed 99223 for initial hospital care and evaluation and management of the patient, supported by requisite documentation from our side. However, the claim was rejected. What could be the reason?

Missouri Subscriber

Answer: You are not alone when it comes to 99223 and 99233 mass denials! According to NGS, a Medicare Administrative Contractor, recent audits have revealed problems with the payer’s review of hospital E/M codes 99223 (Initial hospital care…). Hospital E/M codes had error rates above 70 percent for this and 99233 (Subsequent hospital care…) during the last quarter of 2015. Mostly, the documentation supporting the code levels was amiss, at times even illegible. Other reasons included failure to send medical records, missing the beneficiary’s identification, duplicate services, and the physician billing the claim being different from the one who did the documentation.

NGS also revealed its pre-payment audit results for prolonged service codes 99354-99357, chiropractic codes 98940-98941, and vascular diagnostic studies and osteopathic manipulative therapy, among others. The findings of NGS are quite common. Physicians tend to do a poor job of fully documenting the initial admission and an even poorer job with subsequent hospital visits even though the subsequent visits only require two out of the three key components. Specialists tend to automatically code at the higher levels regardless of the documentation.