Centers for Medicare and Medicaid Services (CMS) recently targeted provider services billed with an Initial Preventive Physical Examination (IPPE) and an Evaluation and Management (E/M) service reported during the same encounter. The review also included services of Annual Wellness Visit (AWV) and an E/M billed during the same encounter. CMS Contractor RELI Group, Inc recently issued Comparative Billing Reports (CBR) to providers who have claims data that have outlier volumes compared to others in their state, specialty, and nationally.
The purpose of the CBR is to compare provider data and identify providers who have a potential of improper payments compared to other claim data. The CBR program main purpose is to support the integrity of claims submission, and adherence to coding guidelines.
If you have received a CBR report, this means the billing patterns differs from the provider’s peers on a state, specialty, and/or national level. Receipt of a CBR report does not necessarily mean an audit is on the heels of a provider or practice.
What was Found in the Comparative Reports?
The analysis looked at both IPPE and AWV services billed with an E/M service during the same encounter. The contractor found HCPCS G0402, G0438, and G0439 billed with an E/M 99201-99215 were often not supported by the documentation. HCPCS G0439 reflected a 29.5% error rate which equates to approximately $192 million in potential improper payments. Between August 1, 2019 through July 31, 2020 over 142,000 providers were identified as rendering providers on claims for IPPE or AWV services with an E/M. The total amount paid on those was over $1 billion.
Correct Coding for AWV/IPPE and E/M
It would be the exception, not the rule, where an AWV/IPPE with an E/M service would be reported during the same encounter. Some provides utilize this billing method to game reimbursement and inflate RVUs if they are compensated under such a model.
An E/M service must be medically necessary and reasonable. This is the overarching criteria in selecting an E/M. Simply renewing a prescription of a chronic disease during an AWV or IPPE does not trigger an automatic E/M service in addition to the AWV or IPPE service.
The distinction is the E/M must be above and beyond what is included in an IPPE or AWV and be separately reportable. The E/M service would have modifier -25 appended to the service. Understand, AWV and IPPE includes addressing chronic disease that are stable and controlled.
States in the Top 10 with the Highest Average of Reporting AWV/IPPE with an E/M
The 2020 Medicare Fee-For-Service Supplemental Improper Payment Data can be found here.