High Denial Rate Cause for Concern

WPS Medicare recently conducted a review of procedure code 99214 for Optometrist in the Missouri and surrounding states. They identified a 48% DENIAL RATE for multiple reasons. The claims samples for these service-specific prepayment probe claims were obtained from Iowa, Kansas, Nebraska, and Missouri. Widespread, service-specific probes are conducted to validate potential systemic problems with billing, utilization, and/or documentation of a specific service.

Records were reviewed to determine whether the procedure code billed met all documentation requirements for the service billed. Services for CPT Code 99214 were denied or reduced if documentation did not support the service billed as defined in Internet Only Manual (IOM) 100-04, Chapter 12, Section 30.6, Evaluation and Management Service Codes - General (Codes 99201 - 99499), located on the CMS Website.

In addition, medical record documentation must meet the following criteria:

• Must be legible;

• Clearly identify patient, date of service, and who performed the service;

• Accurately report all pertinent facts, findings, and observations;

• Include appropriate diagnosis for the service provided;

• Documentation must have a hand written or an electronic signature. Stamp signatures are not acceptable.

CPT Code 99214 requires at least two of these three key components:

• A detailed history;

• A detailed examination;

• Medical decision making of moderate complexity.

Visit the WPS Website which describes the details of the errors: http://www.wpsmedicare.com