National Government Services (NGS), the Medicare contractor for Yale Medical Group, recently published a list of services billed to Medicare that resulted in a significant reduction or denial between July and September 2015. The following reduction/denial reasons were common for all CPT codes reviewed:

• No response to request for medical documentation
• No documentation was submitted for the billed CPT code(s)
• Duplicate services/claims were billed/submitted
• The documentation was incomplete or missing information about the patient
• The rendering physician submitted on the claim form was not the physician who performed the service(s) per the submitted documentation
• Documentation lacked the identification of the beneficiary

The following are examples of specific situations where claims were denied:

Arterial and vascular studies billed the same day, 82 percent reduced/denied for CPT codes 93880, 93882, 93970, 93971, 93925 and/or 93926

Vascular study claims were reduced and/or denied because the documentation lacked clinical indications to support the medical necessity of the study, and/or they were billed with a diagnosis code not listed in the local coverage decision. In addition, a bilateral study was billed even though the documentation supported a unilateral study.

Level 5 established patient visit, 69 percent reduced or denied for CPT code 99215

• Missing and/or incomplete documentation (i.e., no exam or history, no content of counseling)
• Medical decision making did not support the level of service billed.

Initial hospital visit, 79 percent reduced or denied for CPT 99223

This CPT code 99223 requires at least two of these three key components:

• A detailed history
• A detailed examination
• Medical decision making of high complexity

Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit. The reductions or denials were due to the majority of services being recoded to a lower evaluation & management (E&M) level because the record lacked documentation supporting the required key components noted above.

Subsequent hospital visit: 69 percent reduced or denied for CPT code 99233

The reductions or denials resulted from the majority of services being recoded to a lower E&M level because the record lacked documentation supporting the required key components of a detailed history and exam and high medical decision making.