Awareness : Newsletter Articles

Results of First Coast Widespread Probe for CPT 99214

First Coast Service Options Inc. (First Coast) conducted a widespread post payment probe review for CPT® code 99214 for the top three provider specialties billing this code: 06-Cardiology, 11 (internal medicine), and 08 (family practice). The overall widespread probe error rates were 15.79 percent, 19.08 percent, and 24.46 percent, respectively.

Data analysis pertaining to evaluation and management (E&M) services indicated a high comprehensive error rate testing (CERT) error rate. (CPT®) code 99214 (Office/outpatient visit, established patient) has been over-utilized compared to other E&M CPT® service codes. Errors identified include:

  • inappropriate use of high level E&M CPT® codes that were downcoded to a lower level of care due to medical necessity,
  • no medical documentation submitted for the date of service billed, and
  • insufficient documentation to support CPT® 99214
  • Documentation did not meet the “incident to” criteria as outlined in the Centers for Medicare & Medicaid Services (CMS) manual (IOM), Publication (Pub) 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.2;

In response to the high error rate for provider specialty 08 (family practice), continued CERT errors, and risk of improper payments First Coast has implemented a prepayment threshold audit for CPT® code 99214 for claims submitted on or after May 3, 2017.  This applies to all providers for specialty 08 within First Coast’s Florida jurisdiction.