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Physician Outlier Pre-Payment Audit Expansion Reminder

As a reminder, as of January 1, 2021, the Physician Outlier Pre-Payment Audit program now includes, but is not limited to, the CPT® Codes listed below:

  • Telephone evaluation and management service: 99442, 99443
  • Initial observation care: 99218 to 99220
  • Subsequent care: 99224 to 99226
  • Discharge: 99217
  • Admission and discharge: 99234 to 99236

Other audit details

The following criteria is also considered within the scope of the audit:

  • All high-level Evaluation and Management (E&M) services billed with or without a modifier
  • Prolonged services and time-based E&M codes
  • Modifiers associated with E&M services including, but not limited to, modifier 25
  • Modifier 59 (XE, XS, XP and XU)

Additionally, other scenarios where billing patterns seem aberrant to like specialty may be considered for the scope of this program

Note: Only fully insured products are included in the audit with exception of the following: State Health Benefit Program (SHBP) or School Employees' Health Benefits Program (SEHBP), Federal Employee Program® (FEP®), Blue Card claims, Medicare supplementary claims and secondary claims.

If you have questions, please call Provider Services at 1-800-624-1110, weekdays, from 8 a.m. to 5 p.m., Eastern Time.

Published on: March 15, 2021, 17:52 p.m. ET
Last updated on: July 8, 2021, 06:36 a.m. ET