Part B Insider (Multispecialty) Coding Alert

87 percent error rate leads to drastic measures.

If you think CMS is only watching your E/M codes when it comes to the office or hospital, think again. One MAC recently reviewed nursing facility care claims and was stunned at the findings.

NGS Medicare, a Part B payer in four states, announced on Jan. 26 that it had recently audited claims for code 99310 (Subsequent nursing facility care, per day), and found that only 13 percent of these claims were billed correctly.

Based on the outcome of the audit, NGS said that it "will be implementing a prepay edit for CPT code 99310."

Know these quick facts before you report this nursing facility care code in the future.

1. Check documentation for comprehensive interval history, comprehensive exam, and/or highcomplexity medical decision-making. CPT requires documentation of at least two of these criteria before you can bill 99310.

"I imagine that doctors are habitually visiting all their nursing home patients at one time and not documenting enough to meet the levelthree code," suggests Crystal S. Reeves, CPC, CPC-H with The Coker Group in Alpharetta, Ga. Indeed, the NGS report indicates that "most errors occurred because the services were billed at a higher level than was substantiated by the documentation."

Ever since 2008, CPT has published average time spent on the nursing facility codes, allowing you to report them based on time. However, in order for you to bill these visits based on counseling and coordination of care time, the patient must be present during the visit, and you must document the amount of time spent in counseling.

"Documentation must include time spent face-to-face (or on the floor/unit) counseling and/or coordinating care, as well as the total time of the encounter," says Wendy Owens-Frierson, CHM, CHI, CPC with PRSS, Inc. in Miami, Fla.

To read the results from the NGS audit, visit www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21463.