Medicare Compliance & Reimbursement

Hint: Incorrect coding tops the denial reasons for these codes.

Billing subsequent hospital care visits may seem simple at first glance. But, recent CMS data indicates that for Medicare providers, it may be more complex than you think.

Context: Some of the Medicare Administrative Contractors (MACs) have listed CPT^® codes 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity … 25 minutes are spent at the bedside and on the patient’s hospital floor or unit) and 99233 (…A detailed interval history; A detailed examination; Medical decision making of high complexity … 35 minutes are spent at the bedside and on the patient’s hospital floor or unit) on their Targeted Probe and Educate (TPE) active review lists. Some have even revealed their probe results for these codes.

In addition, 99233 was one of the major contributors to E/M services factoring heavily in the Comprehensive Error Rate Testing (CERT) report for FY 2018, with an individual code error rate of 19.1 percent and $365 million in improper payments (see Medicare Compliance & Reimbursement, Vol. 44, No.24).

Here’s a TPE Refresher

Remember, TPE is a Medicare prepayment, claims review process performed exclusively by the MACs. TPE targets at-risk providers and consists of three rounds of review, in which 20 to 40 claims per round are selected for an audit. The MACs decide how many claims a practice must furnish and when to send them.

Practices are alerted by letter; however, audit start dates and providers’ end dates for TPE rounds will vary due to when they receive this letter.

Timeline: The MACs allow 45 days to respond with Additional Development Requests (ADRs). But, MAC NGS Medicare recommends you respond in 30 — “claims will deny on day 46 if the records are not received,” NGS materials indicate.

Heads up: Though TPE is a prepayment review process, the MACs may still request provider records for post-pay probes, NGS indicates. “We aren’t saying that we are never going to do post-payment [reviews], but our goal is to keep it prepay leaning,” says Lori Langevin, NGS provider outreach and education consultant in a TPE webinar.

CMS input: On its TPE website, CMS claims that providers shouldn’t be too worried about the medical review. After all, “providers whose claims are compliant with Medicare policy won’t be chosen for TPE,” CMS maintains. MACs target “providers and suppliers who have high claim error rates or unusual billing practices.”

Even when providers do get chosen for TPE, “the majority that have participated in the TPE process increased the accuracy of their claims,” CMS insists on its website.

The MACs do offer one-on-one education for providers, but that may not always solve some practices’ outlier tendencies. “Any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps,” the agency warns. “These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.”

Check Out the Latest Subsequent Care Codes’ TPE Stats

These frequently used codes are currently in active review for the MACs with published TPE information. Read on for the details.

FCSO and Palmetto GBA: MAC FCSO has 99232 and 99233 atop its TPE to-do list. FCSO doesn’t have results posted, but the MAC offers quick links to help providers boost their ADRs.

Find more information at https://medicare.fcso.com/Medical_review/0407767.asp.

According to MAC Palmetto GBA, the subsequent care codes are on its active review directory as of Dec. 3, 2018, but the Part B carrier lists no results at this time.

Palmetto GBA did, however, publish details on its medical review denials. The options included “Top 10 Part B Medical Review Denials” modules and “JM Medical Review Denials by Category Ranked by Category” overview. Interestingly, the top denial reason related to incorrect coding dominated Palmetto GBA’s E/M and Part B medical reviews for the July 1, 2018 to Sept. 30, 2018 reporting period: “BILER: Claim billed in error per provider,” the MAC data reveals.

See the active medical reviews at www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM Part B~Medical Review~General~9NNJBX6701?open.

CGS Medicare: The Part B MAC offers data for TPE probes performed during the reporting period April 1, 2018 through June 30, 2018.

“Medical Review initiated 61 provider edits during the period of April 1, 2018 through June 30, 2018,” notes CGS. “Twenty-six providers progressed to Round 2 based on previous probe or targeted review results.” The Round 1 findings point out that 99233 remains an outlier problem.

Here are the findings that lead CGS to add “hospital visits” to Round 2:

• Did not meet “the key components required for billing CPT^® 99233, specifically lack of detailed history and medical decision making of high complexity,” CGS notes.
• Failed to submit the requested and required documentation.
• Billed the incorrect provider for the visit.
• Submitted split/shared visit without notes to back up “significant face-to-face by provider,” CGS communicates.

The CGS Round 1 results show that Ohio fared better than Kentucky under the TPE review. Ohio had a hospital visit claims denial rate at 10 percent while 58 percent of Kentucky’s hospital visit claims were denied after the Round 1 probe.

Review CGS’s TPE status update at https://cgsmedicare.com/partb/pubs/news/2018/09/cope8952.html.

Novitas Solutions: Both jurisdictions H and L have their Round 1 results listed for E/M subsequent care, providing easily the most comprehensive TPE probe details of all the MACs.

Here is a breakdown:

• Jurisdiction H: For Round 1, Novitas selected 92 reviews with “30 potentially moving on to Round 2 due to an insufficient sample, moderate or major error rate classification,” says the MAC. The top denial reason was attributed to a combination of incorrect coding and choosing a higher-level code when a lower-level was more appropriate, suggests the guidance. The probe’s time frame is not mentioned, but the MAC notes Round 2 was set to begin in October or November 2018.
• Jurisdiction L: Denial reasons for Round 1 were similar to jurisdiction H, but Novitas pulled only 84 reviews for jurisdiction L, with 21 possibly moving on to Round 2 in December 2018.

Novitas’s TPE stats and tips are available at www.novitas-solutions.com/webcenter/portal/MedicareJL.

WPS, NGS, and Noridian: TPE topics and/or results are not listed on websites for MACs’ WPS and Noridian, but both Medicare carriers give a plethora of advice on responding to medical reviews of E/M services. NGS Medicare lists its pre-TPE medical review focus areas only — 99233 was listed in both of NGS’s jurisdictions as an active topic in 2017.