Medicare audit – new patient codes 99204 and 99205

On November 5th, 2010, posted in: Industry News by

Recently Medicare has determined, after a wide spread audit, that new patient codes 99204 and 99205 were reported incorrectly 73% of the time. As a result, expect pre and post payment reviews of these services. The majority of the errors were due to documentation not meeting a comprehensive history or exam. Attached you will find the comprehensive exam requirements. The exam portion of your documentation has been problematic for some of you for quite some time according to our audits and your report cards. It’s time to pay attention to the detail.

When reviewing the records, Medicare looks for the following in your documentation:

  • Chief Complaint
  • History
  • Exam
  • Medical Decision making

To support 99205, documentation must include:

  • A comprehensive history
  • A comprehensive exam and
  • Medical decision making of high complexity

99204 documentation must include:

  • A comprehensive history
  • A comprehensive exam and
  • Medical decision making of moderate complexity

Medicare requires that the medical record entries for services provided/ordered by authenticated by the author. The method shall be handwritten or electronic signature. Patient identification, date of service and provider of service should be clearly identified.

If they question the legibility of authentication of your signature, they will request an attestation form along with the documentation sent. I suggest each of you have this form available in your office.

In regards to NPP (mid-level providers) remember, in order to bill for these services provided by an NPP under incident to, there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the NPP is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. If services are rendered to a new patient, there is no course of treatment already initiated by the physician, therefore, the service provided by the NPP may not be billed incident to under the physician’s provider number.

Know that we dislike the amount of paper work, rules and regulations just as much as you do. It is our job to communicate what’s happening and why. And hopefully, working together we can achieve compliance and pass any audit that comes about.