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
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 |
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 |
J11: North Carolina, South Carolina, Virginia, West Virginia | 99233 | Unspecified |
| Wisconsin Physicians Service Ins. Corp. | J8: Indiana | 99233 | Unspecified |