NAMAS
Weekly
Auditing Tips
2014
1/10/14
Give Credit for Managed Conditions
One area where auditors struggle is correct assignment in medical decision making when
patients have multiple chronic conditions and/or are currently in inpatient status.
Our physicians do a great job of telling us everything that is going on with the patient, but not
all of these items may be managed by the provider you are auditing. It is important to only give
credit in the medical decision making for those items actively being managed by the audited
physician.
In some cases, this turns our job into detective rather than auditor. You may have to look at
other records in their inpatient stay to see what other specialists may be managing some of
those conditions. For outpatient encounters, it will be done by reviewing notes from other
specialists or looking to see if our physician is responsible for that issue.
An easy answer, I find, is looking at the plan. If diabetes is listed in the assessment, but our
'plan' is to take x-rays of the chest to rule out pneumonia, did we manage the diabetes during
that encounter or is this essentially past medical history? If it's listed in the assessment, it
should have a correlating plan. That plan may be something like "continue on current
medications," but it is your clue that the physician is responsible for that condition or
sign/symptom.
If ever in doubt, ask the physician. You can review the notes with the provider to help explain
what they did during the encounter.
1/17/14
Oftentimes, when we are conducting audits of evaluation and management services (E&M), we
tend to focus on over-coding and overlook visits that are under-coded by providers. It is
important to realize that under-coding is also risky behavior, from both compliance and
profitability perspectives.
The Office of the Inspector General (OIG) has warned that intentionally under-coding visits in
order to minimize risk may be looked at as an incentive (or inducement) for a patient to utilize a
particular provider as their financial responsibilities may be decreased. So, while intentional
under-coding may result in more compliance risk, it could also lead to financial unraveling. If a
provider under-codes established patient visits by just one level, it may only represent $30 per
occurrence; but if it happens 10 times/week, that's $300 and could exceed $15,000/year.
As auditors, we must focus on both under- and over-valuation of professional services. E&M
services should be selected based on the intensity (and overall medical necessity) of the visit.
1/24/14 -Reporting Laparoscopic Service When Specified CPT Codes Do Not Exist
When auditing surgical services that are performed laparoscopically (through a laparoscope),
keep in mind that a laparoscopy code should be reported. If you find that an "open" procedure
code is reported in these situations, credit should not be given as this would represent incorrect
coding. A common misconception is that when a laparoscopy code is not available in CPT, a
provider should report the closest open procedure code. When a procedure is performed
laparoscopically, it should be reported as such, even if that requires the provider to employ an
unlisted laparoscopy code (e.g., 44979 - unlisted laparoscopic procedure, appendix).
Before assigning the final CPT code, providers should always consult Category II and Category III
codes to determine if an accurate code exists. If it does not, rather than assigning an open
code, the provider should select the anatomically appropriate unlisted laparoscopy code and
document each of the following to assist an auditor reviewing a claim or a payer processing the
claim:
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the difficulty of the case
the patient's diagnosis
the risk of complications
the equipment required to perform the surgery
the amount of time and effort required to complete the procedure
When payors require documentation to properly process the claim, the provider should also
provide a cover letter suggesting that the CPT was carefully interrogated and no specific
laparopscopic code could be located. The submitted charge should be based upon the closest
code that does exist with an explanation as to why that code most closely reflects the work
effort and time for the unlisted code.
2/21/14
The Importance of Documenting Comprehensive Histories and Physical Examinations
In order to support the comprehensive level of history, the provider must document the reason
for the visit (chief complaint), at least four (4) elements of the History of the Present Illness
(HPI) [or the status of 3+ chronic/inactive conditions] and a minimum of ten (10) Reviews of
Systems (ROS), and at least one (1) element from each of the patient's past history, social
history, and family history [exceptions apply where we only need to capture 2/3 elements for
established patients, subsequent inpatients and emergency department services]. A
comprehensive examination, according to the 1995 examination guidelines require that
documentation exists specific to a minimum of eight (8) organ systems. Both a comprehensive
history and a comprehensive examination are required for the following levels of service to
name a few:
* 99204 and 99205 (new patient outpatient visits)
* 99244 and 99245 (outpatient consultations)
* 99254 and 99255 (inpatient consultations)
* 99219 and 99220 (initial hospital observation)
* 99222 and 99223 (initial hospital care)
For example, CPT® code 99223 (Initial hospital care, per day, for the evaluation and
management
of a patient, which requires these 3 key components: a comprehensive history; A
comprehensive examination; and medical decision making of high complexity. Counseling
and/or coordination of care with other providers or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s)
requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside
and on the patient's hospital floor or unit and this would never be supported in the absence of
a comprehensive history and a comprehensive examination other than when counseling and
coordination dominate the visit. While auditing many of the above mentioned codes, we have
realized that providers often fall short of documenting the necessary criteria. An auditor must
always confirm that each of these criteria are met to support any of the above mentioned CPT
codes.
2/28/14
Auditing E&M Services When Smoking Cessation is Performed on the Same Date
CMS allows for two (2) "quit attempts" per year, up to four (4) sessions per attempt. As many of
us know, the codes for smoking cessation are time-based codes that require proper
documentation of time in the medical record. Furthermore, in addition to time being
documented, providers must be careful when reporting CPT codes G0436 or G0437, 99406 or
99407 along with E&M service codes (e.g., 992xx).
Smoking Cessation, Preventive (G0436 3-10 minutes & G0437 >10 minutes) are reserved
forpatients who do not have signs or symptoms of tobacco-related disease. Medicare Part B will
pay these services when certain conditions of coverage are met. The ICD-9 diagnosis codes that
should be reported for these individuals are 305.1 (non-dependent tobacco use disorder) or
V15.82 (history of tobacco use). The CMS rule suggests that Medicare will allow 2 individual
tobacco cessation counseling attempts per year during which each attempt can include up to
four intermediate or intensive sessions, for a maximum benefit of up to eight sessions per
year. Smoking Cessation for active smoking related illness (99406 3-10 minutes & 99407 >10
minutes) are reserved for patients who have symptoms related to their current tobacco use and
should be reported with CPT® codes 99406 (intermediate) and 99407 (intensive) for their
counseling efforts.Documentation requires the total amount of time spent during the
counseling portion of the visit. An E&M service is only supported in addition if the modifier -25
is utilized to demonstrate that a "significant, separately identifiable" service was performed.
While auditing such encounters, it is necessary to be sure that the documented time spent in
smoking cessation counseling is distinctly documented. Without sufficient time documentation,
the services should be disallowed. While auditing these types of service for our clients, we find
that the appropriate ICD-9 codes are not properly "linked" to the individual codes, or that the
time spent in counseling is not specifically documented. Be on the lookout for proper time
documentation and accuracy of primary ICD-9-CM codes. Of note: Coding these services will
change with the implementation of ICD-10-CM. Refer to the following codes for ICD-10
application:
Z72.0 -Tobacco use (ICD-9-CM equivalent 305.1)
Z87.891 -History of tobacco use (ICD-9-CM equivalent V15.82)
Resource: CMS
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7133.p
3/7/14
MEDICAL DECISION MAKING = MEDICAL NECESSITY
Established patient E&M Guidelines allow that we may drop the lowest documented portion of
the encounter (history, exam, or medical decision making), but how can an auditor disallow the
medical decision making when it helps define the level of service of the patient. For this
reason, some Medicare Carriers are now allowing that the lowest documented area of the
encounter may be dropped, but that all 3 components must be minimally documented for each
patient encounter unless billed under the rules and guidelines of time based services.
Check the Medicare Carrier Guidance for the Region you are auditing, and be sure of their
specific rules on this matter. Medical decision making and medical necessity walk hand-in-hand
so auditors should always be careful if they do drop this section as the lowest documented
component in the level of service code selection.
3/14/14
Properly Auditing, The Use of Modifiers 62, 80, 82, and AS
The following modifiers are often reported on claims when they are not appropriate and
auditors should always pay careful attention to the RBRVS (Medicare physician fee schedule) to
determine which modifiers are suitable with various CPT codes. The modifiers used to report
assistant-at-surgery and co-surgery are oftentimes confused by provider, biller, coders, etc.,
and it is extremely important to understand the differences, both from compliance and
reimbursement perspectives.
Let's clearly define the modifiers first.
Modifier 62 (Two Surgeons or Co-Surgery):
 Requires that both surgeons author an operative report detailing the specific portions(s)
of the case they performed. The other co-surgeon should also be identified in each
operative report.
 Medicare allows the procedure at 62.5% of the allowed amount (125% total
expenditure).
 Refer to RBRVS to determine if co-surgeons are allowed and if so, if the two-specialty
requirement exists.
 Documentation of medical necessity may be requested.
Modifier 80 and 82 (Assistant at Surgery, Assistant at Surgery When Resident Is Unavailable):
 Both of these modifiers are used to report assistant at surgery; the latter (-82) is only
applicable in teaching hospitals to demonstrate that a "qualified resident" was not
available to assist.
 Payment is allowed at 16% of the allowed amount for Medicare.
 The assistant must be noted in the primary surgeon's operative note but is not required
to dictate a separate report.
 Refer to RBRVS to determine if co-surgeons are allowed and if so, if the two-specialty
requirement exists.
Modifier AS (NPP Assistant at Surgery [e.g., Physician Assistant]):
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This HCPCS II modifier is intended for use when a nonphysician practitioner assists at
surgery.
Medicare reimburses modifier -AS at 13.6% of the allowed amount (85% of the 16%
allowed for MD assist services).
So, when auditing assistant at surgery claims, be sure to first determine whether the cosurgery or assistant at surgery modifiers apply. Second, be sure the appropriate
documentation does exist (e.g., separate operative notes for co-surgeons, (modifier 62). Next, be aware of the payer's policy as it relates to co-surgery or assistant at
surgery for the particular codes in question. And lastly, be aware of the payment rules
that exist.
3/28/14
Auditing Nuts & Bolts
A review of an E&M Encounter for a family practice group had the following findings in each key
component:
CC: Cough and Congestion
HPI: Included all 4 required elements, and demonstrated a patient with a 3-day history of
fever, cough/congestion, and upper respiratory symptoms. The patient states that symptoms
are of moderate severity.
ROS: Included 2 systems properly documented
PFSH: Patient has history of frequent URIs
Exam: Included constitutional, eyes, detailed ENT, and respiratory system, all conveyed as a
laundry list of "normal" symptomology
Assessment: Included a pulse oximetry test
Plan of Care: URI; the patient was given antibiotics with very little additional information.
ANALYSIS:
Based on the HPI of a patient with moderate symptoms and a 3-day history of sickness and
fever, and the fact that the provider performed a pulse oximetry test, we would "assume" the
patient's level of complexity would be at least moderate. However, in this note as it was
audited, the provider did not connect those dots. In the formal analysis, the patient had a
respiratory exam that was essentially normal, and while the patient did have valid complaints of
severity, what was the provider's thinking or reasoning to support the pulse ox? Did the
patient's respiratory status lead the provider to feel that checking their oxygenation was a
needed testing? If these dots had been connected to relate the complexity of a patient with
previous history of recurrent infection, along with a 3-day history of fever and symptoms, then
a higher level of severity would be supported.
All in all, although the documentation components did meet the 99214 level, the medical
complexity of an acute problem with complicating factors was just not exhibited within the plan
of care. If there had been one simple sentence to tie it all together, it would have been
supported. Be sure that when auditing your notes you are evaluating on the premise of medical
necessity and not just the documentation components.
4/4/14
Incident-To
The incident-to rules have not changed, but what is always a variable is the interpretation of
the rules. This tip is not about the incident-to rules, but rather about auditing these services.
Incident-to services require active involvement by both the non-physician provider (NPP) and
the supervising physician (SP). If both did NOT have the active role that is set forth by CMS, the
incident-to service would not have been met. It is the same premise of establishing medical
necessity as any other service. Let's review auditing with consideration of these rules.
 The first golden rule of incident-to is the physician must be on-site. For new patients
and established patients with new problems, this is relatively easy for the auditor to find
by verifying the physician documentation of their face-to-face encounter with the
patient. Therefore, the documentation should reflect what "work" of the encounter the
SP performed that validates that he/she was on-site.
 When auditing the note, documentatin indicating the involvement of the SP must be
found. CMS policy indicates that the SP must initiate the plan of care for new patients
and established patients with new problems. Therefore, the documentation should
include wording/statement that indicates the SP developed the plan of care.
 The SP must remain an "active" role in the patient's ongoing care. While CMS National
Guidance does not adequately define the active role, some of the local carriers more
clearly define this. It is a benchmark that active involvement would include the patient
seeing the SP every 3rd visit.
CMS rules do NOT require the SP to sign off on all of the NPP's charts billed incident-to even
though in many instance their involvement is required. Be sure and check out your MAC for
more information. Noridian has a great full page of information including a chart that is very
easy to follow for incident-to validation.
4/11/14
Documentation Cloning
EHRs allow for templating and copy/paste functionality to help with provider documentation.
This can cause questions about medical necessity and authenticity of the documentation.
Auditors should look for these issues when reviewing medical records. Look for familiarity as
you move from patient to patient for possible incorrect utilization of templating, and evaluate
commonality in documentation from visit to visit of the same patient for possible invalid "carryforward" documentation.
REMEMBER- Using functions such as these within an EHR are not necessarily a violation as long
as the documentation is modified per patient entry to be patient and visit specific.
4/18/14
Auditing Provider Signatures
Verify when auditing EHRs that the appropriate signatures are present (this goes for notes and
orders). EHRs can allow for ancillary staff to contribute to the documentation process; however,
certain rules apply as to what is permitted for ancillary staff assisting the provider versus scribes
in the medical practice. In either case, providers should be aware and continually reminded that
they are ultimately responsible for ALL elements of the documentation, and before they "lock"
a note or physically sign a dictated report, a proper review of each component is strongly
recommended.
4/25/14
Which came first, the code or the service?
AMA created CPT codes to describe services. When those services are E&M visits, auditors,
coders, and physicians sometime forget that the code describes a service, instead of the service
meeting the requirements of a code. Physicians should complete all medically necessary steps
of a visit to evaluate and manage a patient's illness or injury. Then they should document all of
the services performed. Talk with your physician about the difference between medically
necessary visit elements and documentation and what must be documented "to get a level."
Although it is good to understand what elements are included in an E&M code level, do not let
higher codes and potentially higher reimbursement drive up the elements performed in a
service or in documentation. Remember that the service came first, not the code.
This audit tip is part of E&M Coding Clear & Simple by F.A. Davis Company
5/2/14
Auditing Infusion Services:
The updates to the infusion code set are not new, but this area still seems to be troublesome
for many providers and coders. There is a specific hierarchy for proper reporting of these
codes, and add-on services must be appended appropriately. The primary code should always
represent the intended infusion service of the encounter, with the appropriate add-on codes
representing additional infusions, push services, etc., provided to the patient. When auditing
infusion services, an auditor must be keenly aware of ensuring that the code choices for proper
hierarchy are chosen, along with the appropriate add-on service codes, but of MOST
importance are the start and stop times. These codes represent time-based services and not
including time would create non-billable services. In many audits we have found that the time
is not documented to best reflect the actual delivery process of the infusion service.
Additionally, special attention should be noted when infusion services are billed with E&M
services on the same date for scrutiny needed to verify both services.
5/9/14
Documentation of Time with Evaluation and Management Services:
Time is built into the E/M codes so physicians are told to base their E/M selection on the 3
components: History, Exam and Medical Decision Making. Times are listed in the CPT manual
with each level of service as a guideline only.
If a provider spends more than 50% of a face-to-face visit counseling and/or coordinating
patient's care, the provider can code the visit based on time spent even if the History, Exam and
MDM elements are lacking. Time must be documented as well as the detailed description of the
circumstance (counseling patient or coordinating care). For example: 55 minutes spent with
patient, 30 minutes was spent in discussion with patient and family regarding palliative care.
Prolonged service codes can be reported in addition to an E/M code when the length of time a
provider spends with a patient in an outpatient setting exceeds greater than 30 minutes
beyond the typical for the level of service selected.
5/16/14
The Importance of Reviewing Lab Tests
When auditing medical records, it is vital to know what lab tests were ordered, why they were
ordered (medical necessity) and what the tests results indicate. It is not the responsibility or
role of a coder or auditor to interpret lab results; however, it is our responsibility to have the
clinical background and knowledge to understand the results (normal/abnormal) associated
with any tests which were ordered. It is also our responsibility to determine medical necessity
associated with those tests.
A Complete Blood Count and Comprehensive Metabolic Panel are two of the most widely
ordered lab tests. As always, be mindful when auditing "organ or disease-oriented panels"; no
two or more panels should be ordered together that include any of the same constituent tests
from the same patient collection. If the group of tests overlaps two or more panels, report the
panel that incorporated the greater number of tests to fulfill the code definition. You can
report the remaining tests using individual test codes.
Attached you will note a PDF attachment that includes "normal" lab values. These lab values
and disorders are only guidelines, with normal ranges varying from facility to facility, but we felt
that providing this resource to assist you in auditing would be helpful.
5/23/14
Reporting Laparoscopic Service When Specific CPT Codes Do Not Exist
When auditing surgical services that are performed laparoscopically (through a laparoscope),
keep in mind that a laparoscopy code should be reported. If you find that an "open" procedure
code is reported in these situations, credit should not be given as this would represent incorrect
coding. A common misconception is that when a laparoscopy code is not available in CPT, a
provider should report the closest open procedure code. When a procedure is performed
laparoscopically, it should be reported as such, even if that requires the provider to employ an
unlisted laparoscopy code (e.g., 44979 - unlisted laparoscopic procedure, appendix).
Before assigning the final CPT code, providers should always consult Category II and Category III
codes to determine if an accurate code exists. If it does not, rather than assigning an open code,
the provider should select the anatomically appropriate unlisted laparoscopy code and
document each of the following to assist an auditor reviewing a claim or a payer processing the
claim:
 the difficulty of the case
 the patient's diagnosis
 the risk of complications
 the equipment required to perform the surgery
 the amount of time and effort required to complete the procedure
When payors require documentation to properly process the claim, the provider should also
provide a cover letter suggesting the CPT was carefully interrogated and that no specific
laparoscopic code could be located. The submitted charge should be based upon the closest
code that does exist with an explanation as to why that code most closely reflects the work
effort and time for the unlisted code.
5/30/14
Record Evaluation
More scrutiny is on the way! USA Today (5/29, Kennedy) reports that HHS' Inspector General is
set to release a report Thursday revealing that Medicare "paid out $6.7 billion in 2010 for
health care visits that were improperly coded or lacked documentation". Since this represents
such a LARGE amount of the total Medicare budget for these services (21%), Senator Bill Nelson
(D-FL), head of the Senate Special Committee on the Aging, is calling for more scrutiny in
processing and evaluation of services.
This news tip is relevant to 2010 claims, but how are your services documentation and billing
today? Would they stand up to such review? If proper auditing and monitoring was performed
on your services in 2010, then newsbreaks such as this would not be as concerning. Do you
have a Compliance Plan with an ACTIVE auditing and monitoring plan implemented? Having a
defined plan in writing will give guidance so that a proper plan of approach can be constructed
to put feet in motion on your monitoring.
6/6/14
Medical NecessityToday's tip is based on a question submitted by a member this week:
QUESTION: We keep hitting this wall, losing payment because the medical necessity is not
documented in the results of the service. My understanding is that we can use the
documentation by the provider that led up to the decision to do the radiology service, but can
that include the documentation within the encounter note as well (that the documentation in
the providers note can be used). Can you weigh in on this?
ANSWER: Within the medical decision-making process, there are three different components.
First there is the number of diagnoses and/or management options to be considered.
Next comes the amount and or complexity of data to be reviewed. This is the area where a
provider is given credit for ordering and or reviewing of diagnostic tests. Essentially, if the
provider does nothing in terms of ordering and/or reviewing diagnostic tests, they get zero
points in that category. If they order and or review 1 lab or 100 labs, they get one point. The
same would apply to tests the medicine section of CPT or the pathology and laboratory section
of CPT.
The last category of medical decision-making is overall risk. We would suggest you refer to the
table of risk to assess overall risk in consideration for the overall complexity of medical
decision-making. Of those three elements of the decision-making process, two are required to
qualify for a particular complexity.
6/13/14
Prescription Drug Management in the Table of Risk
Prescription drug management has to do with drugs that can only be attained through a
physician order (prescription) and are managed by the physician. The physician assigns a
liability and amount of responsibility to assess for patient risk when a patient receives these
medications, therefore a higher level is warranted with moderate risk. Over-the-counter
medications, even at a prescription dose, are still a lower level of risk based on the classification
and management process of the medication. The fact that a prescription was written for an
over-the-counter medicine is not enough to warrant it as prescription drug management. This
also applies to medications where the insurance will pay if a prescription is written; the logistics
of writing an Rx alone do not allow for the consideration of this drug as prescription
management. Review the documentation content for an actual management process. If the
provider gives the patient a prescription for Prilosec to "manage" their chronic upper gastric
complaints, there is management involved and not merely script writing. Be sure to evaluate
the records thoroughly and not just automatically give credit for all prescriptions written.
6/20/14
On January 6, 2014, the Medicare system began checking the following claims to ensure that
the ordering and referring providers are enrolled in Medicare and that they have a valid
national provider identifier (NPI):
 Part B clinical laboratories
 Part B imaging centers
 Part B durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
 Part A home health agencies.
Without this information, claims will be denied and not paid.
When auditing these types of services, be sure that you are validating that the
referring/ordering physician on the claim form matches the listed referring/ordering provider in
the documentation. It is also suggested that the auditor verify the provider's status on the OIG
Exclusions database as this has become a new, hot topic area for scrutiny.
For complete details about the above, go to SE1305 at www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf.
To access the OIG Exclusions Database, visit:
http://exclusions.oig.hhs.gov.
6/27/14
This week's auditing tip comes from a member's question.
Question: When a physician is asked to see a patient in the ER by the ER physician, should ER
codes (99281-99285) be used, or should we bill POS ER with an outpatient E&M code? If that is
the case, should we bill an established or new patient E&M? There seems to be quite a bit of
discrepancy in how these services are coded.
Answer: This is a very good question and you are right, it is an area with quite a bit of
controversy.
According to CPT Assistant, any provider may use the codes 99821-99285, but that is speaking
to how the codes may be used and is not necessarily the official guidance that all providers
seeing patients in the ED should use. Here is the quote:
Question: Is use of the emergency department services code series (99281-99285) only
limited to emergency department physicians?
AMA Comment: It is important to recognize that the listing of a service or procedure and
its code number in a specific section of the CPT codebook does not restrict its use to a
specific specialty group. Any procedure or service in any section of the CPT codebook may
be used to designate the services rendered by any qualified physician or other qualified
health care professional; therefore, the emergency department services code series
(99281-99285) is not limited to emergency department physicians.
© 2010 American Medical Association
Additionally, it is noted that many carriers have specific guidance/policies in this area. If both
the ED provider and the visiting provider bill with the ED code, the claim may default to the
unspoken rule that the first one who gets their claim in is the one who gets paid, leaving the
other provider to get denied. That leads to political issues between providers and/or the
hospital. In most instances, the visiting provider meets the guidelines as a consultant, a
provider who is being asked to see the patient for their opinion regarding the patient's needs.
In other instances, the visiting provider is there to admit the patient. Both of these instances
rule out the need for both providers to use the ED codes. The handful of cases we are left to
discuss are the Medicare patients, whose providers are technically consultants, but Medicare
does not recognized the consult code any longer. In these situations, instead of the visiting
provider using the ED codes and having conflicts of service, according to the E&M rules, it
would also be appropriate to use the codes 99201-99215 with the POS of ER. These codes not
only represent office-based services, but also outpatient services, as long as the carrier did not
have any conflicting policies.
NAMAS cannot provide you with a crystal clear answer to this controversial scenario, but we
can point you to the process of elimination as noted above and further suggest you check all
carrier rules (commercial and otherwise) regarding any specific policies they may adhere to.
You may also consider constructing an internal compliance policy as to how your practice
addresses these scenarios for consistency in your billing practices.
7/4/14
Clarification to June 27th Auditing Tip
Last week's "auditing tip" regarding the proper use of the Emergency Department (ED)
evaluation and management codes (99281-99285) requires further clarification.
As a result of the moratorium placed on consultation codes by CMS in 2010, the use of
alternative codes has become a point of debate that continues to cause considerable confusion.
While it is noted that CPT codes 99201-99215 may apply to multiple outpatient settings (not
just the office setting; POS #11), CMS does indicate in their Claims Processing Manual, Chapter
12, Section 30.6.11 that a provider treating a patient as a consultant in the ED (for encounters
NOT leading to an inpatient admission) should report the service using a code from the ED
series of CPT (codes 99281-99285) using POS code #23 (emergency department).
We realize that numerous errors in provider reporting and/or claims processing have occurred
as a result of this often debated issue but again, we must fall back on CMS guidance and
established policy. In the event that your claims are submitted in accordance with the CMS
issued policy, we suggest investigating the claims for accuracy and initiating the appeals and
grievances extended by the various payers. We all know that CMS is the standard, but various
payers may have conflicting points of view. For example, some plans continue to allow for
consultations to be reported and in these cases, we suggest submitting claims to those payers
accordingly.