Additional Documentation Requests: Don't ignore them

Family physicians in the Medicare J5 MAC region states of KS, MO, NE, and IA providing inpatient care should be prepared to receive and promptly respond to letters from the WPS Medicare Medical Review Department. These will be related to prepayment review of claims for subsequent hospital visits submitted with code 99233. WPS notes that their Comprehensive Error Rate Testing (CERT) reviews of paid claims have shown a significant increase in errors on claims for these services by family physicians. If one of your claims is selected for review, WPS will send an Additional Documentation Request (ADR) for medical records for all dates of service billed with CPT code 99233.

Breathing a sigh of relief because you are not in one of the J5 MAC states? I can see that. No one wants their payments delayed and subjected to prepayment review and potential denial or down-coding. But if your Medicare CERT or one of the myriad other Medicare auditors isn’t looking at your inpatient hospital services, I would bet they are looking at some other evaluation and management (E/M) service that may have been inadequately documented or incorrectly coded. If post-payment review results in a high error rate, you too may find your payments delayed, reduced, or denied.

So what can you do to avoid problems?

First respond promptly and completely to all ADR letters. Many claims are denied and counted as errors due to lack of response to ADR's. See the information previously provided in this blog for details

Second, be sure that documentation submitted is clear, complete, appropriately signed, and dated. Did you and your partner provide E/M services on the same date and bill the services according to Medicare rules as one E/M service? Will both notes be sent? If not, your 99233 visit may be down-coded to 99231 or 99232. A records request checklist can help your staff submit all of the information necessary to support your charges.

Finally remember, code 99233 requires at least two of these three components:

• A detailed interval history – state progress or complications since last visit, if referring to previous history state date of previous history, chief complaint or reason for visit beyond “follow-up,” HPI (4 items or 3 conditions), ROS (2-9 systems), PFSH (none necessary);

• A detailed examination – Extended exam of problem system/areas plus others;

• Medical decision making of high complexity (2 of 3 elements, not risk alone) – established problem(s) worsening; new problems with or without further work-up; changes in treatment, nursing instructions, decisions for palliative care, tests and procedures ordered (note if urgent), tests reviewed and unexpected results, discussions with other physicians, risks of management and treatment.

It is complex and probably annoying but remember, it is necessary to show the work (talking, reviewing, thinking) that you did to support your charges. A 99233 service should not go unpaid due to lack of response to ADRs, unsigned records, or other documentation gaps.