High-Intensity Claims Review Process

Following is a summary of what our process for reviewing high-intensity E&M claims is:

• We review claims from physicians whose high-intensity E&M claims coding practice is above the 75^th percentile for their specialty as compared to Milliman and Robertson (M&R) data. Our review is focused on all lines of business, except the following:

• We are reviewing the following eight E&M codes:

• We will review biannually the list of participating and nonparticipating physicians whose coding practices are above the 75^th percentile for their specialty.

• Humana will not routinely require claim-by-claim medical record justification for any physician whose coding practice is below the 75^th percentile for his/her specialty. If Humana’s review demonstrates that medical records consistently support high-intensity claims submitted by a particular physician, that physician also will be exempt from ongoing focused review.

• Physicians may also submit related medical records at the time of claim submission. Due to our system’s limitations, some physicians who submit medical records at the time of claim submission might still receive a subsequent letter requesting medical records, which should be ignored. To facilitate prompt payment of appropriate high-intensity codes billed, we encourage you to submit records at the time a claim is submitted.

• Physicians whose coding practices are above the 75^th percentile for their specialty will receive a letter or a statement on their remit notice requesting them to submit medical records for review.

• Physicians will be asked to submit supporting medical documentation for each claim that is reviewed. Humana does not reimburse for the cost of providing medical information.

• If the medical record is submitted, a review is conducted according to standard coding criteria and a determination is made based on the medical documentation submitted. The claim is either paid at the level submitted based on the review of the supporting medical documentation or it is adjusted to the appropriate level. This includes upcoding the claim if documentation supports a higher level than billed.

• Coding criteria can be found at the following Web site address: http://cms.hhs.gov/. After you reach the site, in the bar on the left, under programs, click on "Medicare." Under "Medicare Professional and Technical Information," scroll down and click on "Documentation Guidelines for Evaluation and Management Services." Click on "1995 version in PDF format" to access the information. By using these guidelines to code claims, you should be able to meet the criteria and code claims accurately. Please note that the coding criteria utilized are 1995 Centers for Medicare and Medicaid Services (CMS, formerly Health Care Financing Administration or HCFA) guidelines, incorporating the 1997 definition for single organ system examination which further clarifies and expands the single organ system examination section. The American Medical Association (AMA) has put together additional information located in the front of the Evaluation and Management section of the CPT manual.

• If the physician does not submit supporting medical documentation, the claim is adjusted (i.e., level 3 if a level 4 or 5 is submitted). This allows timely payment, pending later receipt of documentation. Claims will not be adjusted lower than a level 3.

• An explanation will appear on the physician’s remittance notice as to why payment for the submitted claim was adjusted.

• Physicians in states that mandate provider appeals will have the ability to appeal decisions per their state's required process. Physicians from all other states should follow the process of submitting a request for re-review. Please feel free to call your customer service center for more specific instructions on how to submit a claim for re-review.

• Humana reserves the right to conduct focused reviews of all physician practices that submit claims to ensure they are billing correctly.

We have shared our revised process for reviewing high-intensity E&M claims with local medical associations in order to more objectively assess our process.

We have also learned that many physician practices are interested in obtaining additional information regarding accurate coding procedures.

Therefore, we are seeking to sponsor educational seminars by certified coding trainers with medical groups and local medical associations as a means of helping practices nationally comply with CMS guidelines. Please call your local medical director if your office or group would like additional information. Please also let your medical director know if your office or group would like to partner in sponsoring an educational session.