CMS requires Medicare Administrative Contractors to conduct a wide range of billing audits as part of its Medicare Integrity Program. These audits include a program called medical review, in which auditors conduct pre-payment and post-payment claims reviews.
MACs publish a list of the current procedural terminology codes they target for pre-payment reviews, as the codes have a history of fraud or abuse. For instance, the MAC for Pennsylvania, Novitas, is targeting CPT code 99205, which designates a comprehensive office visit for new patients across all provider specialties, and CPT codes 99222 and 99223, which designate initial hospital visits, billed by the following specialists: cardiology, gastroenterology, pulmonary medicine, infectious disease, internal medicine and family practice.
Novitas is also targeting CPT code 99214 as part of a “widespread prepay probe” into upcoding abuse. CPT 99214 is the code for an extended office visit.
More articles on revenue cycle management issues:
How to build payer-provider collaboration for a more efficient RCM
Olathe Health, Midland tap Cerner for RCM, Verify selects Conifer & More — 12 RCM keynotes
Full-page ad bashes CHS-owned hospital over billing, quality
