Bill Medicare Correctly for Prolonged Services — Part 2

TrailBlazer recently evaluated a sampling of Medicare claims, looking at documentation for prolonged services with direct patient contact (CPT codes 99354–9935), as well as the associated evaluation and management (E&M) services. It concluded it had paid in error $82.50 of every $100 for these claims from practices in Texas, New Mexico, and Colorado.

In addition to denying claims for documentation errors associated with prolonged services TrailBlazer denied payment (in part or in whole) for the E&M and other services in the sample of claims reviewed for one or more of the reasons below. Be sure to avoid these errors.

  •  Documentation did not support medical necessity: 
    • The patient presented for predetermined therapy or treatment; billing of an E&M service was inappropriate.
    • Purpose of the visit was for laboratory testing results without an acute or substantive change in the patient’s chronic or established condition.
    • Chief complaint was absent, ambiguous, or not addressed in the history, physical exam, or medical decisionmaking (MDM).
    • Frequency of E&M services billed per beneficiary for CPT codes 99212-99215 exceeded the documented needs for management of stable, chronic conditions in the absence of an acute problem and/or change in treatment plan.
    • Local Coverage Determination requirements for other reported procedures were not met. This included condition coverage criteria, procedure documentation requirements and/or proof of physician proficiency in performing the testing procedures.
    • Physician certification or physical therapy plans of care were not submitted.
    • Testing procedure codes were unbundled in appropriately using the 59 modifier when a single comprehensive CPT code exists for the service performed.
  • Documentation did not support the occurrence of face-to-face encounter with the patient (e.g.,reporting E&M service codes for telephone calls and no direct patient contact). 
  • Documentation was illegible or contained insufficient information to support the non-E&M CPT code reported on the claim.
  • Prolonged services codes were reported in place of the procedures performed for the patients. The services were recoded with the correct procedure CPT code.
  • Documentation failed to meet the key components for the E&M service reported:
    • Description of presenting problem or chief complaint was inadequate.
    • History component documentation was minimal or absent.
    • Review of systems was incomplete or could not be identified.
    • Physical exam documentation was sparse or not present in the record.
    • Physical exam documentation did not address the presenting problem.
    • MDM was not high complexity, which is required when reporting the highest-level new patient office visit and initial nursing facility care codes.
    • Patient’s condition(s) did not meet the clinical description typically associated with the selected code.
  • E&M visits were determined to be low-intensity services regardless of the amount of history and physical exam documented. Extensive listings of chronic, stable conditions were unrelated to the presenting problem or its treatment plan.
  • Frequency of E&M services billed per beneficiary exceeded the documented needs for management of stable, chronic, or improving conditions.
  • Documentation was submitted without physician’s orders or treatment plans that may have led the reviewer to underscore the MDM.
  • Subsequent hospital care codes were reported at the highest level for stable, improving patients with no change in the established treatment plan.
  • An E&M service was reported with the incorrect E&M code family.
  • An E&M service was reported instead of the surgical procedure code.

Did you know you can earn up to 20 AMA PRA Category 1 Credits™, per physician, when a TMA Practice Consulting performs a Coding & Documentation Review for your practice? TMA’s certified professional coders and auditors will determine whether your practice is following payers’ guidelines for appropriate billing by evaluating CPT and ICD-9 coding and medical record documentation as well as billing documents such as encounter forms, claims, and the corresponding explanations of benefits You will receive recommendations to correct any problems in a written report within 30 days. For details, or to speak with a consultant, call (800) 523-8776, or email

Published March 28, 2012 

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