I currently work in an SIU and we have been given a lead on a provider who is submitting claims for reimbursement on Prolonged E&M code 99354. The Policy of the health plan is to request supporting documentation for the services for review and then make the determination to pay or deny per the review of the documentation. When we receive the documentation is does not support the Prolonged services and the 99354 is denied.

The provider will then submit a dispute with altered, not amended documentation, not corrected, completely altered, and request payment for the Prolonged Service.

We are working towards education of the provider in the hopes that they are unaware that this is illegal but we need to provide them with all of the proper documentation to support our determination that they cannot do this. We have the Medicare Guidelines on how the amendments, corrections, and addendums are supposed to be done, MLN Matters SE1237. What I’m looking for are specific guidelines or Medicare requirements stating that these cannot be added after a claim has been denied for level of service just be able to get paid for the level of service.

Can anyone help with this?