An Audit From Anthem for Misuse of 99212?

Q: I had a friend who was audited by Anthem for their use of 99212, an office visit and now they are requesting a large refund stating its use was improper. I, like my friend, perform an evaluation of my patient daily. Why does this not qualify as billable service? Furthermore, why do they pay for an E&M and later ask for it back, they should not pay it in the first place.

Evaluation & Management Codes

Thanks for this question as I have been inundated with similar inquiries not only from practitioners but also malpractice carriers who defend providers during audits. It appears there is a lot of bad or incorrect information circulating among licensed acupuncturists and the use of evaluation and management codes. In short, it is not appropriate to bill an E&M code daily as the acupuncture codes have an inherent pre, intra, and post evaluation associated with the service. This same inherent nature of pre, intra and post evaluation is the same for all providers including chiropractors, physical therapists, and medical doctors who provide direct care.

Please think of an E&M not as an office visit but an examination as that is what the intent is most often for a LAc. An office visit by a LAc may include several services one of which may be an exam but also may be acupuncture and therefore to separate the term "office visit" exclusively to an E&M may lead to improper use.

It is clear and compulsory that an acupuncturist must perform an initial E&M to record the history, perform an exam, determine the nature and extent of the condition as well as institute a plan of care. However, due to the pre, intra, and post-service inclusion of the acupuncture codes there must be a 25 modifier appended to the E&M code to distinguish that the evaluation was indeed separate and identifiable above and beyond the inherent day to day evaluation associated with the acupuncture. This is exactly stated in the 2018 Professional Edition of CPT. In fact, this language has been a part of the codes for acupuncture from their first inclusion in CPT as well as when the codes updated in 2005.

Understanding Pre, Intra & Post-Service

Where I believe the confusion lies is that there is a lack of understanding of the level of pre, intra, and post-service evaluation is associated with acupuncture and that on a typical follow-up visit it is simply inclusive. Please note the following of what is considered inclusive;

PRE Service may include a review of:

• Review of patient complaints and interim history
• Communication with other providers (when necessary & appropriate)
• Preparations for care

INTRA Service may include:

• Discussion about the service with the patient
• Pertinent evaluation and assessment of the patient
• Performance of the acupuncture service (hand washing, insertion, stimulation, and removal)
• Monitoring of the procedure
• Retention without direct face-to-face time does not count towards the time for billing of acupuncture

POST Service work includes:

• Evaluation and discussion with the patient about the effect of treatment
• Documenting the service
• And when necessary- arrangement of additional services or referral to another provider, discussion of the case with other providers, and review of literature about the patient's condition

Based on this it is clear the day to day review and evaluation is inherent. Hence why when a provider bills E&M daily it may be reviewed. It is possible a patient may require an E&M daily when and if there is a significant issue above and beyond the current status such as a new incident/injury, new complaint, or sudden significant change and though possible not probable.

It is also generally reasonable to do a detailed reevaluation about every 30 days when a patient is under continuous care to ascertain the patient's progress. As a consequence, the billing of an E&M about every 30 days is reasonable and understood as typical.

But, as you have noted insurances will simply often pay for the E&M assuming it was appropriate but then later, based on the frequency and pattern being unusual request records and audit the veracity of the frequent or daily use and hence your friend's dilemma.

A Different Type of Audit

Note they are essentially taking your word that the code is appropriate and make payment but when the pattern appears unreasonable they will review. The review does not mean what you are doing is inherently incorrect but they will verify it is such.

This type of audit also occurs when multiple sets (3-4 or more typically) are done as this high level of use though not improper on its face is unusual and requires much more documentation of time and separate insertions.

Yes, you do indeed do an evaluation daily as you do a review of the complaint and how it is changing, along with an evaluation even if only tongue and pulse but these duties are inherent to the acupuncture services performed.

Note medical providers do often bill each visit with E&M code but they also are not performing any treatment nor do they see the patients as frequently as someone under acupuncture care protocols which can be from 1-3 times per week for several weeks. Chiropractors and physical therapists like acupuncture providers have an inherent evaluation with their services and too cannot bill a separate E&M on each visit.

If you believe you can qualify for an E&M daily (not likely) you must be able to demonstrate a significant issue or need above and beyond the typical day to day evaluation you perform as part of your care plan. Otherwise, like your friend and many others it can lead to recoupment of payments.