tci Medicare Compliance & Reimbursement - 2011 Issue 7
Medicare Error Rates: Reporting 'Low-Level' 99211? You Still Need Complete Documentation, One MAC Reminds
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Article Overview
This article discusses a Medicare contractor’s review of claims involving a low-level established patient evaluation and management service and the documentation issues identified in audit results. It is aimed at coders, billers, compliance staff, and clinical practices that submit Part B claims and want to better understand documentation expectations, audit risk, and general guidance from a Medicare administrative contractor.
Why This Topic Matters
Even low-level office visits can trigger documentation and medical necessity scrutiny, and audit findings may affect compliance risk for practices. The article helps readers understand the type of record support Medicare contractors expect when reviewing claims for this service.
What You Will Learn
- How Medicare audit activity can identify documentation problems in low-level E/M claims
- Why complete record support matters for claims review and compliance
- What broad types of encounter documentation are emphasized in contractor guidance
- How related services and separately reported procedures may be discussed in an audit context
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Practice managers
- Physician office staff
- Revenue cycle teams
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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