August 8, 2008
Comprehensive Error Rate Testing Consultation Services
The Centers for Medicare & Medicaid Services (CMS) uses the Comprehensive Error Rate Testing (CERT) program to measure and improve the quality and accuracy of Medicare claims submission, processing and payment. Under this program, numerous randomly selected claims are reviewed each year. The results of these reviews are used to characterize and quantify local, regional and national error rate patterns. CMS uses this information to address the error rate through appropriate educational programs.
One area showing an error rate pattern includes Consultation Codes (CPT Codes 99241 thru 99255). Consultation requirements are as follows:
Basic Requirements:
- Request from an appropriate source (MD/DO, NPP)
- Render the Medically Necessary Evaluation
- Report in writing back to the requesting provider
Consult Do's
- NPPs may request and/or perform consultations if State practice
and licensure requirements are met, and within their skill and
competency level
NOTE: High level consult codes billed by NPPs may be subject to medical review.
- Consults may be requested from other members of the same group as long as requesting and rendering providers are of different specialties and all requirements of a consult are met
Consult Don'ts
- Cannot be performed as a shared/split visit
- Follow-up to a consult should not be billed using a consult code
NOTE: In both instances use the appropriate subsequent care or established patient visit code
