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Urology Coding Alert

Bad Documentation Prolongs Agony of Carrier Scrutiny

Published on Tue Jun 21, 2005

Most prolonged service denials result from poor documentation - but neatness counts, too

Even if your documentation isn't perfect, you still have a good chance of getting that prolonged services code paid, right? Not so fast. One carrier found errors in every CPT 99354 claim it reviewed - read on for what they found, and how you can avoid the same fate.

HealthNow, the Medicare Part B provider for upstate New York, conducted a review of their claims for +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]). The result? A 100 percent error rate - not a single claim they examined held up to scrutiny.

Among the problems HealthNow found:
 
  •  No medical necessity. In 95 percent of the claims, the documentation did not support medical necessity for prolonged care. The records did not show "an acute illness or outstanding event" that necessitated the extra care.
     
  •  No record of time. Some claims failed to document how much time the physician spent in the patient encounter. Without documentation of time spent in minutes, virtually no claim for time-based codes will be paid.
     
  •  No physician of record. Other claims failed to identify the physician who provided the service.
     
  •  No legibility. The handwriting was simply not legible in 8 percent of the claims.
     
  •  No patient supervision. One record HealthNow reviewed stated that the patient was kept unsupervised in the waiting room for two hours during the office visit, with no face-to-face care provided during that time.
     
    Lesson learned: "Documentation must state that the patient presented with a situation that requires additional face-to-face time over and above the usual office visit," said Barbara Adams, RN, local provider education and training specialist for HealthNow, in a presentation.

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