Medicare Compliance & Reimbursement

Caution: Don’t use the same code for every visit.

Chances are your nurse practitioners (NPs) are performing higher-level E/M services every day. Plus, because these codes are perennial favorites, they sit atop most Medicare claims reviewers to-do lists. To avoid issues down the road, you may want to periodically review if your NPs are documenting and reporting these codes appropriately.

That’s what auditors sought to determine as part of a new comparative billing report (CBR) compiled by RELI Group, Inc., which the Centers for Medicare & Medicaid Services (CMS) contracts to develop, produce, and distribute CBR reports. The firm undertook an investigation after learning that NPs had an improper payment rate of 8.2 percent in 2019, covering four high-level E/M codes, said RELI’s Annie Barnaby during a recent presentation on the topic.

The four codes and their respective improper payment amounts for NP services were:

1. 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity…):

• 15.3 percent improper payment rate, representing over $203 million

2. 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity…):

• 18.8 percent improper payment rate, representing over $93 million

3. 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity…):

• 5 percent improper payment rate, representing over $423 million

4. 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity …):

• 9.9 percent improper payment rate, representing over $108 million

The RELI team then analyzed NP claims for these E/M services that were submitted between Feb. 1, 2019 and Jan. 31, 2020. Check out the metrics the team reviewed, along with their findings and tips on how you can prevent these issues at your practice.

Check the Percentage of Allowed Units

“Metric 1 looks at the percentage of allowed units for new and established patient E/M levels 4 and 5,” Barnaby said. “This metric tells us, of all the evaluation and management services performed through the analysis year, what percentage of those were for these high-level service codes?”

To find these numbers, the analysts divided the total number of allowed units for each of the individual CPT^® codes separately by the allowed units for CPT^® codes 99201-99205. Those results were then multiplied by 100 to get the percentage.

The national rates of allowed units for these codes were:

• 99204: 33.48 percent
• 99205: 5.08 percent
• 99214: 48.95 percent
• 99215: 3.62 percent

Practices should compare their stats with these national percentages. If you are significantly higher than the averages, it’s possible that reviewers may soon be scrutinizing your claims. For instance, if 40 percent of your NP’s established patient office visits were billed with 99215, then they are significantly higher than the average — and you’ll stick out like a sore thumb to reviewers.

Warning: When reporting E/M services, if you are constantly reporting the same E/M code (such as 99214) for every E/M encounter that your NP performs, then you will be inviting trouble. You might soon end up facing an unnecessary audit and other problems if you report the same E/M code for every E/M encounter.

Even though you might find that most of your NP’s E/M encounters are pointing toward one of the E/M codes, you should not automatically reach for the same code each time they perform an E/M service. Instead, look through the documentation, properly account for all the components of the E/M service, and then arrive at the proper code for the encounter.

Although you might have to spend more time in identifying the appropriate code for the encounter, you will save your practice precious time and money in the long run by avoiding the risk of an audit that turns up inappropriate coding.

See the Percentage of Beneficiaries Who Received Level 4 and 5 Visits

Another metric from RELI looks at the percentage of beneficiaries that received high-level CPT^® codes. “This final metric lets us take a step back to examine the beneficiaries who received these high-level services,” Barnaby noted. “What percentage of the beneficiaries that the nurse practitioner saw received a high-level evaluation and management code?”

To determine this figure, the analysts divided the total number of beneficiaries who received services for the individual CPT^® codes by the number of beneficiaries for each code set, she said.

The national percentage of beneficiaries whose claims were billed with level 4 and 5 E/M codes were:

• 99204: 34.54 percent
• 99205: 5.32 percent
• 99214: 61.89 percent
• 99215: 6.32 percent

As with the first metric above, you should check your records to ensure that you aren’t dramatically above the averages. Although that may not necessarily mean you are billing improperly, it’s still a great way to prompt further investigation to ensure that all of your codes are reflected in the documentation.

Red flags: CPT^® regulations currently require all three components — history, examination, and decision making — for a new patient E/M service unless you’re billing based on time. The encounter you describe in the notes must satisfy all three of these requirements before you report 99204 or 99205. Ensure that your documentation reflects these elements. Although that will change in 2021, the reality is that you must still meet these requirements until the calendar turns.

In addition, it’s possible that auditors could be looking to ensure that these percentages don’t change dramatically when the new coding system is put into place. Just because you’ll have a new method for calculating code levels in 2021 doesn’t mean you will suddenly be billing four times the number of 99205s than you are now, for instance. Keep a close eye on the documentation and ensure that every code is justified, both now and under the 2021 rules.

Resource: Read the entire comparative billing report on the RELI website at https://cbr.cbrpepper.org/About-CBR/CBR-202006.