News: Documentation key to getting HCPCS code 99234 right

CDI Strategies - Volume 13, Issue 6

Insufficient documentation. That’s the biggest reason for improper payments for Healthcare Common Procedure Coding System (HCPCS) code 99234, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, according to a Comprehensive Error Rate Testing (CERT) study of claims submitted from April through June 2017.

In order to submit that code, the documentation needs to include three components, according to the January 2019 Medicare Quarterly Compliance Newsletter:

  • A detailed or comprehensive history
  • A detailed or comprehensive examination
  • Medical decision-making that is straightforward or of low complexity

CERT reported that claims with insufficient documentation lacked one or more of the following:

  • A properly authenticated record (e.g., a legible signature)
  • Documentation to support the services were provided or other documentation required for payment of the code
  • Hospital record
  • Valid physician’s order that includes all elements required by regulation, Medicare program manuals, and Medicare Administrative Contractor (MAC) specific guidelines

For example, when the CERT asked for documentation related to billing for HCPCS code 99234, the physician submitted a discharge summary note for the billed date of service, Revenue Cycle Advisor reported. Then, when a medical reviewer requested additional documentation, the physician sent only a history and physical note for the billed date of service. There was no billing physician’s order to support the observation services billed, as Medicare policy requires. As a result of insufficient documentation, the medical reviewer scored the claim as an insufficient documentation error and the MAC recovered payment from the provider.

For information, see the Medicare Claims Processing Manual, Chapter 12, Section 30.6.8, on payment for hospital observation services and inpatient care services, or read the Medicare Quarterly Compliance Newsletter.

Editor’s note: This article originally appeared in Revenue Cycle Advisor. To learn more about the CERT, read this Q&A with Sharme Brodie, RN, CCDS.

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