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maryanneheath

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Hi everyone,

Boy I could sure use some help here. A specialty provider is billing a level 99215 AND a prolonged services code for EVERY PATIENT and EVERY VISIT. :eek: He does schedule an hour for each patient, and he does document the time well. I am really concerned about this and am wondering if anyone has any good articles / guidelines / something tangible I can show to the provider. Technically, yes, he has time documented correctly. And yes, as a specialty provider he does see some complicated cases. However, I have a hard time believing that every single patient warrants this kind of billing. Just to satisfy my curiosity, auditing by key components revealed level 99214s, and in a couple of cases, 99213s.

I hope I am making sense to you guys. Any help would be greatly appreciated.
 
to bill a 99215 plus prolonged you must meet the crteria for the 99215 by the three key components then only if total time spent exceeds 75 minutes can you bill both. If the criteria meets a 99213 and total time exceeds 45 minute then you can bill both. a 99214 total time must exceed 65 minutes.
 
I would advise him to be very careful about misuse/overuse of the prolonged services codes. It's very easy for Medicare to analyze billing trends and see who is billing an excessive amount of prolonged services.

As you can see from the FBI.gov press release, the government will bring federal charges against individuals who intentionally submit fraudulant cliams.

The claim submitted by the health care provider requires a physician to state a diagnosis and provide a procedure code—called a Current Procedural Technology (CPT) code—identifying services rendered. Medicare regulations require that each provider certify that the services rendered were medically necessary and were furnished by that provider. A warning at the bottom of the form specifically states that any false claims or statements in relation to the submission of a claim for reimbursement are prosecutable under federal or state law.

In most instances during the relevant time period, Reaves submitted forms that falsely claimed she had provided prolonged service visits to her patients in order to induce Medicare to make payments to her that were significantly higher than the payments she should have received.

Reaves routinely billed Medicare using codes that would have required her—under Medicare regulations and depending on the corresponding service—to spend between 60 and 150 minutes with a patient. Many of the claims Reaves submitted would have required her to spend a minimum of two-and-a-half hours of face-to-face time with her elderly clients, when she actually spent far less. As a result, Medicare reimbursed Reaves more than $511,068 for the fraudulent prolonged service visits Reaves claimed to have made.

Reaves faces a maximum potential penalty of 10 years in prison and a fine of the greatest of $250,000 or twice the gross gain or loss caused by her offense. She will also be required to forfeit the proceeds of her crime. Sentencing is currently scheduled for July 13, 2013.
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How's that for a good article to show the provider? Just remember, regardless of what the schedule says - is it medically necessary to spend 75+ minutes with each patient, and is he documenting that?
 
Thank you both very much for your replies. I will show the provider this press release. The documentation of time is there, it's just that I think the medical necessity might not be in all cases. It's a difficult thing, as "technically" he is documenting time appropriately and accurately. On the other hand, with the medical decision making aspect, as well as the medical necessity, I am afraid he is really dancing with fire.

Have a wonderful Wednesday! :)
 
How do you guys feel about billing an E&M (documentation matches the level), except no mention of the time "Dr. X" spends with the patient?

"Dr. X" also bills an injection (20610/20550/20553) along with a 99354 on almost every patient, every visit. He ONLY mentions that after the injection: "The patient was observed face to face for 30 minutes during which time vitals were monitored.".

I feel that the observation is included in the post op of the injection, so that 30 minutes he's documenting doesn't mean much in regards to the 99354.

If there is NO time documented in the Office Notes, except this blurb mentioned above, do you feel we're leaving ourselves open to being audited? Is this documented anywhere in CPT?
Thanks!
 
beckipoff said:
How do you guys feel about billing an E&M (documentation matches the level), except no mention of the time "Dr. X" spends with the patient?

"Dr. X" also bills an injection (20610/20550/20553) along with a 99354 on almost every patient, every visit. He ONLY mentions that after the injection: "The patient was observed face to face for 30 minutes during which time vitals were monitored.".

I feel that the observation is included in the post op of the injection, so that 30 minutes he's documenting doesn't mean much in regards to the 99354.

If there is NO time documented in the Office Notes, except this blurb mentioned above, do you feel we're leaving ourselves open to being audited? Is this documented anywhere in CPT?
Thanks!
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I believe you are correct about observing a patient after an injection should be included. Other key points:

99354 is an add-on code to outpatient E/M codes. So if he is billing it without it's primary code, it likely isn't being paid anyway. Still shouldn't be billed, but at least there shouldn't be a ton of overpayments that would need to be refunded.

Is he himself actually staying in the room to observe the patient face-to-face for 30 minutes?! I find it hard to believe that any MD would do this...Most would delegate that to ancillary staff. Either way, I don't feel billing the prolonged visit code in this situation is justified.

Just my $0.02 :)
 
Hi Meagan,
Thanks for the quick response!

I don't have direct access to the Dr. :(

He is also billing a 99214 (which I do feel is well documented to support this) but it's the issue of him not notating any actual time spent during that E&M that I'm struggling with.
To bill the 99354 I'd like to see something that shows he spent 25 minutes with the patient for the E&M and then the extra time (at least 30 minutes) he is mentioning to justify the 99354. The only time documented is the 30 minutes he states he face-to-face observed the patient to monitor vitals after the injection(s).

What is that 30 minutes was done by a Nurse checking in on the patient every few minutes? That shouldnt't justify the 99354 either.
 
beckipoff said:
Hi Meagan,
Thanks for the quick response!

I don't have direct access to the Dr. :(

He is also billing a 99214 (which I do feel is well documented to support this) but it's the issue of him not notating any actual time spent during that E&M that I'm struggling with.
To bill the 99354 I'd like to see something that shows he spent 25 minutes with the patient for the E&M and then the extra time (at least 30 minutes) he is mentioning to justify the 99354. The only time documented is the 30 minutes he states he face-to-face observed the patient to monitor vitals after the injection(s).

What is that 30 minutes was done by a Nurse checking in on the patient every few minutes? That shouldnt't justify the 99354 either.
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Oh ok, I see.

Well, I also agree that he would need to document total time spent with the patient for the "primary" E/M code. Even if that is documented, I still don't feel that the time spent observing a patient after giving an injection is billable. Especially not if the nurse is the one who is checking on the patient to account for the "prolonged time"!!
 
mhstrauss said:
Oh ok, I see.

Well, I also agree that he would need to document total time spent with the patient for the "primary" E/M code. Even if that is documented, I still don't feel that the time spent observing a patient after giving an injection is billable. Especially not if the nurse is the one who is checking on the patient to account for the "prolonged time"!!
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Do you know of anything (from AMA, etc.) that I can pass along that might show that the time must be documented for the primary E&M?

And thanks again. :)
 
beckipoff said:
Do you know of anything (from AMA, etc.) that I can pass along that might show that the time must be documented for the primary E&M?

And thanks again. :)
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You're quite welcome :)

Check out this MLN article; pages 3-4 talk about time documentation, and the face-to-face component. I'm not sure it's exactly what you're looking for, but it might help :confused:

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM5972.pdf

I haven't come across anything from the AMA.

Hope this helps!
 
That article was actually pretty helpful. Page 4 it states "Make sure that you document the start and end times of the visit, along with the date of service."
Now......If I can only find something from AMA that states the same. :)
Thanks again!

Becki
 
beckipoff said:
That article was actually pretty helpful. Page 4 it states "Make sure that you document the start and end times of the visit, along with the date of service."
Now......If I can only find something from AMA that states the same. :)
Thanks again!

Becki
Click to expand...

NO KIDDING!!
This thread was very helpful. Thanks!
 
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