Outpatient Facility Coding Alert - 2016 Issue 5
E/M Coding: NGS Medicare: Majority of 99215 Claims Were Coded in Error
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Article Overview
This piece examines an NGS Medicare pre-payment review focused on established-patient office/outpatient evaluation and management billing and the documentation problems that led to denials or reductions. It is aimed at coders, billing staff, auditors, and clinical practices that bill higher-level E/M services and want to understand the general categories of audit findings and documentation expectations discussed in the article.
Why This Topic Matters
High-level E/M claims are closely scrutinized, and documentation gaps can lead to denials, recoupments, or audit risk. Understanding the audit themes helps practices improve recordkeeping, claim accuracy, and response readiness for payer reviews.
Article Sections
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Audit overview and context
Introduces the NGS Medicare pre-payment review and the general scope of the claims examined. It frames the article as a summary of audit findings and practice-focused prevention tips.
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Documentation and claim issues identified in the audit
Reviews the main categories of problems cited in the audit, including medical record support, readability, completeness, claim accuracy, and response to documentation requests. The section also references related Medicare documentation expectations and signature requirements at a high level.
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Related modifiers and submission considerations
Touches on duplicate service concerns and the general use of repeat-service modifiers in the context of claim submission. It provides broad administrative context without detailing coding decisions.
What You Will Learn
- What an NGS Medicare pre-payment review focused on
- Which broad documentation issues commonly trigger reductions or denials
- Why record legibility and completeness matter in audit situations
- How claim accuracy and documentation consistency affect payment review outcomes
- What general submission and response practices can help reduce audit problems
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Compliance auditors
- Physicians and other clinicians who document E/M services
Codes Discussed
Modifiers Discussed
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