Orthopedic Coding Alert

Question: I have heard that Medicare is taking a closer look at claims for 99214. Why is this happening?

Michigan Subscriber

Answer: Citing evaluation and management (E/M) as an area of common payment errors, HCFA is refocusing its compliance efforts on E/M code 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires a detailed history and examination and medical decision-making of moderate complexity) The scrutiny stems from HCFAs belief that practitioners are overfiling for this level of service when a lower-level code is more correct.

In June 2000, HCFA sent a letter to Part B providers stating that 99214 accounted for a significant portion of the coding errors in the last two audits. In fact, documentation for many of these services was found to be sufficient to support services more appropriately described by 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires a problem focused history and examination, and straightforward medical decision-making).

Part B providers are expected to scrutinize their own E/M coding and take a harder look at whether 99214, a high-level code, is the most appropriate for the care being administered.


Answers to You Be the Coder and Reader Questions provided by Heidi Stout, CPC, CCS-P, coding and reimbursement specialist at University Orthopaedic Associates in New Brunswick, N.J.; Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C.; Vicki L. Hayworth, CPC, insurance specialist for Boone Orthopaedic Associates, LLC in Columbia, Mo.; Karole Lee, clinic administrator at Helena Orthopaedic Clinic in Helena, Mont; Mary Campbell, CCS-P, reimbursement analyst for Camino Medical Group in Sunnyvale, Calif.