May 2004 Medicare Bulletin - Idaho Insert
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Table of Contents
PCA Widespread Probe 99202 and 98940-98942
CIGNA Government Services
Contractor Information
Contractor Name
CIGNA Government Services
Contractor Number
05130
Contractor Type
Carrier
Article Information
Article Database ID Number
A19139
Article Type
Basic Article
Article Version Number
1
Article Title
Widespread Postpay Education- 99202
Is the AMA CPT / ADA CDT Copyright Statement Required?
No
CPT codes, descriptions and other data only are copyright 2003 American
Medical Association (or such other date of publication of CPT). All Rights
Reserved. Applicable FARS/DFARS Clauses Apply. CDT-4 codes and descriptions
are © 2002 American Dental Association. All rights reserved.
Primary Geographic Jurisdiction
ID
Article Publication Date
05/01/2004
Article Beginning Effective Date
05/05/2004
Article Ending Effective Date
Article Text
Progressive Corrective Action (PCA) was developed by the Centers for Medicare
& Medicaid Services (CMS) to conduct medical review through sampled
claims to validate potential errors and to educate providers concerning
the errors. The goal of PCA is to lower the error rate. PCA probe reviews
may be conducted either on a pre-payment or post payment basis.
In February 2004, a widespread post payment probe review was conducted on
CPT code 99202*- Office or other outpatient visit for the evaluation and
management of a new patient which requires these three key components: An
expanded problem focused history, an expanded problem focused examination
and straightforward medical decision making.
One hundred (100) claims were reviewed for this probe review. Twenty (20) providers were selected based on their utilization of CPT code 99202*. The calculated error rate for this probe review was 11.01%. 13 records were down-coded to 99201*. 7 records were scored at a higher level of service than was billed.
In March 2004, a widespread post payment probe review was conducted on CPT codes 98940-98942*-Chiropractic Manipulative Treatment (CMT).
One hundred (100) claims were reviewed. Twenty (20) providers were selected
based on their utilization of CPT codes 98940-98942*. The calculated error
rate for this probe review was 39.44%. The overwhelming error that was identified
was the lack of documentation to support the services billed. The documentation
requirements for Chiropractic manipulative treatment services can be found
in the Idaho LCD on Chiropractic Services # 97-001. This policy was published
in the Medicare Bulletin in March/April 2000 in the Idaho insert. This policy
is also located on our website at www.cignamedicare.com. The following documentation
requirements are taken from the policy:
(The following documentation requirements apply whether the subluxation
is demonstrated by x-ray or by physical examination.)
Initial visit:
1. History and present illness
- Symptoms causing patient to seek treatment
- Family history if relevant
- Past health history (general health, prior illness, injuries, or hospitalization, medications, surgical history)
- Mechanism of trauma
- Quality and character of symptoms/problems
- Onset, duration, intensity, frequency, location and radiation of symptoms
- Aggravating or relieving factors
- Prior interventions, treatment, medications, secondary complaints
These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal), and joint (anthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling or spasticity. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and chest pains are also recognized as symptoms, but in general other symptoms must relate to the spine as such. Subluxation must be casual, i.e. the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.
2. Physical examination: Evaluation of musculoskeletal. nervous system.
To demonstrate a subluxation based on physical examination (rather than
X-ray) two of the following four criteria are required (one of which must
be asymmetry/misalignment or range of motion abnormality):
- Pain/tenderness evaluated in terms of location, quality and intensity
- Asymmetry/misalignment identified on a sectional or segmental level
- Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility)
- Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament
3. Diagnosis:The primary diagnosis must be subluxation, including level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. Either a Category I, II, or III diagnosis should also be indicated.
4. Treatment Plan: The treatment plan should include the following:
- Recommended level of care (duration and frequency of visits)
- Specified treatment goals
- Objective measure to evaluate treatment effectiveness
5. Date of treatment (initial or exacerbation)” Include explanation of treatment provided and the note must be authenticated (signed or identity of the clinician performing the service should be clearly indicated).
Subsequent visits:
A. History
- review of chief complaints, changes since last visit
- system reviews if relevant
- exam of area of spine involved in diagnosis
- assessment of change in patient condition since last visit
- evaluation of treatment effectiveness
C. Documentation of treatment given on day of visit. The note must be authenticated (signed or identity of the clinician performing the service should be clearly indicated) All documentation must be legible including the identity of the performing provider. Failure to do so will result in denial of claim(s).
Coverage Topic
Doctor Office Visits
Other Comments
Does this Article contain a “Least Costly Alternative”
provision?
No
Approval Notes
Approved?
No
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This Article has no Related Documents.
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(04-0802)
Idaho Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 No longer classified as HPSA, effective 3/1/98
2 No longer classified as HPSA, effective 10/1/98
3 Classified as HPSA, effective 10/1/98
4 No longer classified as HPSA, effective 1/1/99
5 Classified as HPSA, effective 10/1/99
6 Classified as HPSA, effective 12/1/99
7 No longer classified as HPSA, effective 9/1/01
8 Classified as HPSA, effective 3/1/02
9 No longer classified as HPSA, efective 3/1/02
10No longer classified as HPSA, efective 9/1/03
11Classified as HPSA, effective 9/1/03
(04-0874)
