If you were thinking that CMS under the Trump administration might go easier on providers in an audit situation, think again.
A veteran auditor for both the recovery auditing (RAC) program and the Comprehensive Error Rate Testing program (CERT) confides that CMS and its contractors have turned their attention to hospital-based E/M services with a vengeance – and they are hitting pay dirt there, mostly because of incomplete physician documentation.
The Obama-era CMS, by contrast, focused mostly on audits of office visit claims, the auditor explains.
For the foreseeable future, practices should make sure their physicians are adequately documenting level 2 and 3 initial hospital visits (99222 and 99223). A good number of these claims are getting downcoded to a low-level rounding visit (e.g. subsequent hospital visit code 99231). Contractors are pulling claims from 2015 and 2016 for audit.
Recoup requests or reduced payment on just a few of these claims will add up fast – code 99222 pays $139 per visit, while 99223 pays $205. A level 1 initial hospital visit (99221) pays $103 (all fees par, not adjusted for locality).
Remember that level 2 and 3 initial hospital visits require a comprehensive history and exam. Medical decision-making complexity must be moderate to achieve a level 2 visit and high for a level 3.
Physicians use initial inpatient codes to report hospital-based consultations for Medicare patients, as well as the first hospital encounter by the admitting doctor.