Medicare Visit Reviews

June 14, 2011

Can Medicare require documentation that includes the full physician's note for 99204s and 99205s?

Question: The rumble around the physician's lounge is that Medicare is now requiring that you send in the note for all 99204 and 99205 visits in order to be paid. Can they do that? How do they do that?

Answer: This could be true depending what state you are in. Highmark in New Jersey sent out a notice that they would be requiring pre-payment review of all 99204 and 99205s due to a 73 percent error rate on review. Even commercial carriers do this from time to time to motivate providers to bolster their supporting documentation. In the case of Highmark, they found deficiencies in the comprehensive history and exam areas on these higher level new patient codes. It is somewhat surprising that they did not mention decision making on the 99205s as that can be difficult to master. The history and physical exam issues are likely more of a housekeeping variety.

You could also be hearing about what has been dubbed "ask first, pay later." Beginning in 2011, new legislation requires CMS to change their methodology of paying claims first and doing reviews later - also called "pay and chase" - and adopt billing software designed with predictive modeling capabilities. So there is the answer to whether they can do that. How they do it? It has to be manual, so you are in the hands of auditors. As to the local issue, if it applies in your state it is likely limited in duration - it must be expensive and these types of reviews are typically short-lived, unless the results and subsequent downgrading of claims outweigh the cost.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at or

This article originally appeared in the February 2011 issue of Physicians Practice.