The correct reference for auditing claims coded as 99214 is the 1995 and 1997 CMS Documentation Guidelines. These guidelines are essential because they provide the necessary criteria for determining whether the documentation supports the level of service coded. Specifically for 99214, which is used for an established patient with a moderate level of complexity, the guidelines outline the requirements for history, examination, and medical decision-making that must be met in order to justify the coding of this particular level of visit.
Using the CMS Documentation Guidelines is critical during the auditing process, as they detail the elements that must be present in the patient’s medical record to substantiate the coding decision. They help auditors assess whether the claims were appropriately coded based on the documentation provided by the healthcare provider.
In contrast, while other sources such as the ICD Coding Guidelines or the CPT Coding Manual may provide valuable information, they do not replace the specific CMS guidelines when it comes to the detailed documentation standards required for E/M coding and billing compliance. The U.S. Government Accountability Office Reports also do not specifically address coding requirements or documentation standards relevant to E/M codes, such as 99214. Thus, the focus on the 1995 and 1997 CMS Documentation Guidelines is what makes it the correct