Medicare Part B Contractor Denies 96% of Neurology Claims in Recent Probe

Wisconsin Physician Services (“WPS”), the Medicare Part B Carrier for providers in Michigan, Illinois, Minnesota and Wisconsin, recently conducted a service-specific probe review of Current Procedural Terminology (“CPT”) 99233 billed by neurology providers. WPS found that only 4 percent of billed claims were payable. 96 percent were denied or down-coded.

CPT 99233 is a hospital evaluation and management procedure code, which requires at least two of the following three components: (1) a detailed history; (2) a detailed examination; and (3) medical decision making of high complexity. When CPT 99233 is billed, the presenting problems are of moderate to high severity, and the physician typically spends 35 minutes at the bedside and on the patient’s hospital floor or unit.

WPS denied/down-coded 96 percent of the claims at issue in the service-specific probe for the following reasons:

• The documentation did not support a face-to-face service (32 percent)
• The provider failed to submit requested documentation (32 percent)
• The documentation provided was insufficient or incomplete (30 percent)
• The documentation supported another procedure code (2 percent)

Significantly, nearly one-third of the claim denials were made when the physician failed to submit requested documentation. It is essential that providers and suppliers adhere to all requests for documentation issued by Medicare and its contractors to avoid potentially unnecessary claim denials/payment recoupments.

WPS has issued an article describing documentation problems and ways to prevent them.

For more information regarding this and/or other Medicare audit or reimbursement matters, please contact Abby Pendleton, Esq. or Jessica Gustafson, Esq. at (248) 996-8510 or visit The HLP website.