WPS' Service Specific Prepayment Probe Results for Established Patient Office Visits (99213) for Illinois

Wisconsin Physician Services (WPS)–the Medicare Administrative Contractor (MAC) for Michigan, Illinois, Wisconsin and Minnesota–regularly conducts Service-Specific Probes (Probes) "to validate potential systematic problems with billing, utilization, and or/documentation of a specific service." In a recent Probe, 99213–the billing code for established patient office visits–became the focus, with the sample drawn from Illinois for all specialties. In reviewing the Probe results, WPS considered 101 services from 100 randomly-selected-claims for 99213 from all specialties (with no more than 5 claims from any one provider). Of those 101 services, 48.51% were allowed as billed and 51.49% were denied. The 51.49% denied services were attributed to three major problems: Documentation Not Received (27.72%) – It is the provider's responsibility to furnish documentation upon request. The provider has 45-days in which to respond with the requested information or the claim will be denied. Documentation Did Not Support the Level of Service Billed (22.77%) Improper Selection of Procedure Code (0.99%) WPS reminds providers that medical documentation must meet the following criteria to avoid claim denials: Must be legible; Clearly identify patient, date of service, and who performed the service; Accurately report all pertinent facts, findings, and observations; Include appropriate diagnosis for the service provided; and Documentation must have a hand-written or an electronic signature. Stamped signatures are not acceptable.

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