Medicare Prepayment Review of E and M Services

TheCMS Medicare Administrative Contractor (MAC), Palmetto GBA recently published the results from prepayment reviews of Evaluation and Management codes 99204 and 99205.

Evaluation and Management services are the most commonly provided service and the most likely to be subject to miss-coding.  CMS and individual MAC’s have published numerous guides, fact sheets and even an interactive coding tool to assist providers in selecting the proper level of the E and M service.

 Follow these links for helpful information on E and M coding:

Documentation Guidelines for Evaluation and Management (E/M) Services

Evaluation and Management Services Guide

E/M Review Checklist and Score Sheet Tool

This brought to my attention, maybe there are other MAC’s currently scrutinizing the same or similar services in their jurisdictions.  And, maybe there are providers out there that are unaware that they are undergoing a “Prepayment Review” when they are passing on their charge code to office staff.  So, with that in mind, I researched the information found on each MAC website and compiled a location and procedure list.  Since the procedures selected are known to be both performed at a high volume and have a high error rate, by reviewing the criteria for these codes, a provider can ensure he/she is compliant when making a code selection.

MAC	Jurisdiction/State(s)	CPT Code(s)	Specific Provider Types Effected
Cahaba Government Benefit administrators	J10: Alabama, Georgia, Tennessee	99214-99215 99223, 99233	Unspecified
Cigna Government Services	J15: Ohio	99310	Unspecified
First Coast Service Options	J9: Florida	99201-99205 99211-99215 (when billed with a 24 modifier)	Unspecified
First Coast Service Options	J9: Florida	99215	General practice Optometry Osteopathic manipulative medicine Pediatric medicine Podiatry
National Government Services	J6: Illinois, Minnesota, Wisconsin	99205, 99215 99223, 99233	Unspecified
National Government Services	J13: Connecticut, New York	*99223 **99233 ***99215	* General Surgery ** Cardiology and Gastroenterology ***Hematology/Oncology
Palmetto GBA Click herefor results	J1: California
	Northern California	*99204 **99205	*Family Practice and Ophthalmology ** Internal Medicine and Neurology
	Southern California	*99204 **99205	*Otolaryngology **Internal Medicine and Neurology
Palmetto GBA Click here for results	J11: North Carolina, South Carolina, Virginia, West Virginia	99233	Unspecified
Wisconsin Physicians Service Ins. Corp.	J8: Indiana	99233	Unspecified