In 2001 the Medicare program paid approximately $1.1 billion for consultations that did not meet all of the Medicare and Current Procedural Terminology (CPT®) coding requirements. This figure represents approximately 33% of the total dollars paid for consultations. Findings revealed that 19% of the consultations billed did not meet the definition of a consultation, 47% were billed as the incorrect type or level of consultation, and 9% of the consultations billed did not have supporting documentation. Approximately 95% of the consultations reported at the highest level of service (eg, 99245, 99255) or as follow-up consultations were miscoded. (Note that at the time of review, the CPT codes for follow-up consultations had not yet been deleted.)

Why are this Medicare study and its findings important to general and specialty pediatric practices? As you are aware, state Medicaid programs and most third-party payers are advised of Medicare health care fraud and...

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