CMS to Audit for Code 99233

CMS to Audit for Code 99233

Correct documentation is crucial for physician billing to Medicare. Over the past few years, The Department of Health and Human services has been strongly focused on correcting and minimizing healthcare fraud. Currently, evaluation and management (E/M) services are under high scrutiny, especially CPT code 99233. What does this mean for your practice, and how can you protect your assets? We’ve compiled a list of three ways to prepare for random CMS audits of 99233.

Background on Code 99233

If you’re familiar with physician billing, then you know the CPT code 99233 is the highest billing code for subsequent inpatient hospital visit. In order to properly bill the code, you need at least two of the following three components:

  • Detailed interval history
  • Detailed examination
  • High complexity medical decision making.

A recent review showed that providers in Illinois used code 99233 approximately 15 percent more often than the national average. Additionally, of the records that were reviewed, 54 percent were inaccurate. Due to these numbers, Illinois will be one of the states CMS will focus on the most for random audits.

Preparing for Audits

Because Medicare only allows the “medically necessary” portion of face-to-face visits as billable, it’s important for physicians to be aware of what is considered medically necessary by CMS. Many physicians and office managers leave their billing up to specific employees. If this is the case in your practice, be sure all staff members are familiar with Medicare’s guidelines and know what to look for when billing. Here are three ways to prepare your practice for random CMS audits.

  1. Stay current on Medicare physician billing guidelines and regulation changes. One way to stay informed is by signing up for the electronic newsletter, Connects, that CMS sends out each Thursday.
  2. Familiarize yourself and your staff with previous improper payment findings, so that you know what to look for and avoid when billing. Here are some resources for you:
    1. Recovery Audit Program
    2. Comprehensive Error Report Testing
  3. Regularly review – or have a staff member review – all claims in your physician billing program to make sure no errors have been made and that sufficient supporting documentation is available.

Available Help

Wading through Medicare’s regulations is no easy task. Physicians everywhere occasionally make billing mistakes, usually by accident. Keeping yourself educated and reviewing your billing process is the best way to prepare yourself for a random audit. However, there’s no shame in seeking help if you’re in over your head. That’s where Healthcare Information Services (HIS) steps in. To learn more about code 99233 audits and how HIS can benefit your practice, contact us today.


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Image courtesy via: Stuart Miles/freedigitalphotos.net



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