First Coast (FCSO) begins 100% Prepayment Audits for 99215

First Coast Service Options (FCSO) announced on its webpage late last week that it was beginning a 100% prepayment audit of code 99215 as of January 18, 2013. All 99215 claims submitted after this date are subject to audit; it affects a number of specialties, specifically including Optometry Services.

Pre-payment audits mean that ALL claims submitted for a particular service are placed on hold until a review of the submitted records is completed. A few significant items are important to note:

No time frame is noted for completion in the 99215 announcement above; generally these take 30-60 days, although it could be longer.
Each 99215 claim is reviewed individually; they are not “grouped together” for each practice TIN or provider NPI.
At the conclusion of the FCSO audit, practices will receive either a denial or reimbursement for each 99215 submitted.
FCSO notes that practices must be able to support the medical necessity for this level service.
FCSO provides some provider help via their E/M services page (link here) and their E/M FAQs (link here).

All coverage areas within the FCSO jurisdiction are affected: Florida, Puerto Rico, and the US Virgin Islands. The FCSO link to the Florida announcement can be found here. All other coverage areas for Part B within FCSO have identical announcements. Of note, ophthalmology is not included on the list for this particular prepayment audit by FCSO, although ophthalmologists should be aware of the scrutiny 99215 is facing and FCSO’s guidelines as well..

Optometric practices and combined ophthalmology and optometric practices should be aware of this and review the appropriateness of their coding for all of their claims, not just 99215. If you are concerned about your coding accuracy, Corcoran Consulting Group is an expert in this area and can help. For more information, contact us via phone or web.