WPS Conducting a Widespread Service-Specific Prepayment Probe

Attention physicians, according to the WPS website, they are conducting a widespread Service-Specific Prepayment Probe on CPT code 99213, using samples obtained from Wisconsin, Illinois, Michigan and Minnesota for all specialties. This probe arises after a Medical Review analysis of claims in the May 2009 sample period revealed 217 CERT errors.

This specific probe will involve a random sample of 100 claims submitted from a cross-section of all providers and suppliers who bill the particular service. The medical records will then be requested for the sample and reviewed.

Similar to other audit situations, an Additional Documentation Request (ADR) Letter will be sent requesting medical records for services of CPT code 99213 billed on claims for the probe. WPS will utilize the information in the medical records to evaluate all services on the claims identified in the ADR request. Once an ADR letter is received, the providers have 30 days to submit the requested documentation. Failure to do so in a timely fashion may result in denial or reduction of services. Keep in mind that it will be important to submit all relevant documentation. This upcoming audit activity should be no surprise to the physician community as we continue to see an increase in all type of audits.

The HLP recommends that physicians take a careful look at their documentation practices as compliance continues to take on critical importance in this health care environment.

For more information, you can contact Abby Pendleton, Esq. at (248) 996-8510

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