ED Coding & Reimbursement Alert - 2016 Issue 3
Medicare News: Medicare Payer Reports Problems with 99215 Use
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Article Overview
This piece summarizes a Medicare payer review of claims involving a high-level established-patient office/outpatient E/M service and explains the documentation and claim-submission problems identified in the review. It is aimed at coders, billing staff, and compliance teams that need to understand the kinds of recordkeeping and claim-quality issues Medicare contractors may scrutinize. The article also references related CMS guidance and mentions a couple of repeat-service modifiers in the context of duplicate-claim concerns.
Why This Topic Matters
It helps practices understand why high-level E/M claims may fail pre-payment review and highlights the types of documentation and administrative errors that can trigger denials, recoupments, or delays.
Article Sections
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Overview of the Medicare pre-payment review
Introduces the payer review and the general focus on higher-level evaluation and management claims. Summarizes the time period and the broad outcome of the review.
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Reasons claims were reduced or denied
Outlines the main categories of documentation and claim-submission problems identified in the review. Each item is followed by general advice related to avoiding similar issues.
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Reference to the complete audit results
Points readers to the external source for the full prepayment audit results and related payer information.
What You Will Learn
- What types of documentation deficiencies can affect high-level E/M claims
- What broad claim-processing issues may lead to denials or recoupments
- How Medicare contractor review concerns are described in the article
- What general areas of supporting documentation are emphasized for compliance
Who Should Read This
- Medical coders
- Billing staff
- Compliance teams
- Physician practices
- Revenue cycle professionals
Codes Discussed
Modifiers Discussed
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