Medicare: Call Centers Need to Improve Responses to		 
Policy-Oriented Questions from Providers (16-JUL-04, GAO-04-669).
                                                                 
In 2002, GAO reported that the Centers for Medicare & Medicaid	 
Services (CMS) needed to improve its communications with	 
providers who deliver medical care to beneficiaries. GAO reported
that 85 percent of the responses it received to 61 calls made to 
call centers operated by Medicare carriers--contractors that help
manage the Medicare program--were incorrect or incomplete. GAO	 
also found that CMS's primary oversight tools were insufficient  
to ensure accuracy in communication. GAO was asked whether call  
centers now provide correct and complete information to 	 
providers. GAO (1) reviewed carriers' effectiveness in providing 
correct and complete responses to policy-oriented telephone	 
inquiries and CMS's efforts to improve communications with	 
providers and (2) evaluated CMS's efforts to provide oversight of
carrier call centers.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-669 					        
    ACCNO:   A10933						        
  TITLE:     Medicare: Call Centers Need to Improve Responses to      
Policy-Oriented Questions from Providers			 
     DATE:   07/16/2004 
  SUBJECT:   Customer service					 
	     Data integrity					 
	     Evaluation methods 				 
	     Health care programs				 
	     Information resources management			 
	     Monitoring 					 
	     Performance measures				 
	     Telecommunication					 
	     Telephone						 
	     Policies and procedures				 
	     Medicare Program					 

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GAO-04-669

United States Government Accountability Office

GAO 	Report to the Ranking Minority Member, Subcommittee on Health, Committee on
                    Ways and Means, House of Representatives

July 2004

MEDICARE

    Call Centers Need to Improve Responses to Policy-Oriented Questions from
                                   Providers

GAO-04-669

Highlights of GAO-04-669, a report to the Ranking Minority Member,
Subcommittee on Health, Committee on Ways and Means, House of
Representatives

In 2002, GAO reported that the Centers for Medicare & Medicaid Services
(CMS) needed to improve its communications with providers who deliver
medical care to beneficiaries. GAO reported that 85 percent of the
responses it received to 61 calls made to call centers operated by
Medicare carriers- contractors that help manage the Medicare program-were
incorrect or incomplete. GAO also found that CMS's primary oversight tools
were insufficient to ensure accuracy in communication.

GAO was asked whether call centers now provide correct and complete
information to providers. GAO (1) reviewed carriers' effectiveness in
providing correct and complete responses to policyoriented telephone
inquiries and CMS's efforts to improve communications with providers and
(2) evaluated CMS's efforts to provide oversight of carrier call centers.

July 2004

MEDICARE

Call Centers Need to Improve Responses to Policy-Oriented Questions from
Providers

Only 4 percent of the responses GAO received in 300 test calls to 34 call
centers were correct and complete. GAO posed four policy-oriented
questions 75 times each to carrier call centers. The level of correct and
complete responses for each individual billing question ranged from 1 to 5
percent. The majority of remaining responses were incorrect, or partially
correct or incomplete. Several factors, including fragmented sources of
information, confusing policy information, and difficulties in retaining
the CSRs responding to calls appear to account for the lack of correct and
complete answers. There are many call centers serving other industries
that triage incoming calls by first identifying the nature of the call and
then distributing it to the CSR who is best qualified to respond. Although
CMS has not adopted this approach, it is currently implementing two other
initiatives that may improve CSRs' access to information. However, neither
initiative is specifically designed to support CSRs responding to
policyoriented questions.

In addition, CMS's efforts to provide oversight of carrier call centers
are inadequate. Although CMS requires carriers to monitor the performance
of their call centers, the standards used and the technological resources
available to evaluate performance do not allow carriers to thoroughly
assess whether CSRs' responses are correct and complete. In addition,
CMS's own monitoring efforts are too infrequent. CMS only performed one
contractor performance evaluation related to carrier telephone services in
fiscal year 2002 and none were performed in fiscal year 2003. Moreover,
when performed, these evaluations did not provide sufficiently detailed
information to assess CSRs' performance.

Provider Call Centers' Responses to Four Policy-Oriented Questions for
Billing Medicare To improve the responses to policy-oriented inquiries
from providers, GAO recommends that CMS develop (1) a process to route
policy inquiries to staff with the appropriate expertise, (2) clear and
easily accessible policy-oriented material to assist customer service
representatives (CSR), and (3) an effective monitoring program for call
centers. CMS generally agreed with the recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-04-669.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Leslie G. Aronovitz at (312)
220-7600.

Contents

  Letter

Results in Brief
Background
CSRs' Responses to Policy-Oriented Questions Were Largely

Incorrect Call Center Oversight Does Not Adequately Assess CSRs'

Responses to Policy-Oriented Questions Conclusions Recommendations for
Executive Action Agency Comments

                                       1

                                      4 5

                                       7

13 16 17 18

Appendix I Scope and Methodology

Appendix II Carrier Call Center Accuracy Test Questions

Appendix III
Comments from the Centers for Medicare & Medicaid Services

  Appendix IV GAO Contact and Staff Acknowledgments 30

GAO Contact 30 Acknowledgments 30

  Tables

Table 1: Summary of Accuracy of CSR Responses by Question 8 Table 2:
Questions and Answers for Test of Carrier Call Centers 23

Abbreviations

CMS Centers for Medicare & Medicaid Services
CPE contractor performance evaluation
CPT current procedural terminology
CSR customer service representative
FAQ frequently asked question
IVR interactive voice response
MMA Medicare Prescription Drug, Improvement,

and Modernization Act of 2003 NGD Next Generation Desktop OT occupational
therapist PT physical therapist PPS prospective payment system SLP speech
language pathologist

This is a work of the U.S. government and is not subject to copyright
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separately.

United States Government Accountability Office Washington, DC 20548

July 16, 2004

The Honorable Pete Stark Ranking Minority Member Subcommittee on Health
Committee on Ways and Means House of Representatives

Dear Mr. Stark:

In fiscal year 2003, Medicare paid more than $271 billion to health care
providers for medical services to about 41 million elderly and disabled
beneficiaries. Since the creation of Medicare in 1965, an extensive body
of statutes, regulations, policies, and procedures has been promulgated
that specifies what the program will pay for, and under what
circumstances. Because of the complexity of the program and the high
volume of claims submitted annually-about 930 million in fiscal year
2003-it is critical that physicians and other providers who bill Medicare
have access to clear and comprehensive information about the program.

One of the responsibilities of the Centers for Medicare & Medicaid
Services (CMS)-the federal agency that manages the Medicare program- is to
communicate program information to medical providers so that they can bill
the program properly. To facilitate communication, in fiscal year 2001,
CMS expanded the responsibilities of the contractors1 that assist it in
managing the Medicare program to include the operation of toll-free
assistance call centers for providers. These call centers were established
to respond to the information needs of providers serving Medicare
beneficiaries.

Carriers' call centers responded to over 21 million provider inquiries in
fiscal year 2003. The majority of these calls were status-oriented calls,
in

1The contractors that process Part A claims, which cover inpatient
hospital, skilled nursing facility, hospice, and certain home health
services, are referred to as fiscal intermediaries. The contractors that
process Part B claims, which include physician services, diagnostic tests,
durable medical equipment, and related services and supplies, are referred
to as carriers.

which providers2 checked the status of a claim in the payment process or
sought confirmation of an individual's eligibility for Medicare. However,
providers also called with more complex, policy-oriented questions
regarding a variety of topics such as Medicare coverage, medical policies,
program changes, and billing requirements that affect their ability to
receive Medicare payment.

In 2002, we reported3 that the responses we received to 85 percent of 61
calls we made across five carrier call centers posing policy-oriented
questions were incorrect or incomplete. We found that some customer
service representatives (CSR) who respond to provider inquiries lacked
ready access to easily searchable databases, limiting their ability to
respond to providers' inquiries. We also found that CMS's primary tools to
oversee these call centers-carrier self-monitoring and contractor
performance evaluations (CPE)-were insufficient to ensure accuracy in
communication. In addition, we noted that there was a lack of
standardization in the type of technological resources available among
call centers, which affected both CSRs' access to information and
carriers' ability to conduct self-monitoring. CMS agreed improvements were
needed and said it had a variety of initiatives under way to help enhance
carrier call center communications. At the time we performed our work,
these initiatives were too new for us to evaluate. You expressed concern
about whether the call centers now provide correct and complete
information to providers.

You asked us to reexamine how well call centers communicate with
providers. Specifically, we evaluated (1) carriers' effectiveness in
providing correct and complete responses to policy-oriented telephone
inquiries and CMS's efforts to improve communications with providers and
(2) CMS's efforts to provide oversight of carrier call centers.

To determine carriers' effectiveness in providing correct and complete
responses, we placed a total of 300 calls to 34 carrier call centers and
posed questions, similar to those from Medicare providers, concerning the
proper way to bill Medicare in order to obtain payment from the program.
Our questions included a variety of circumstances commonly encountered

2In this report, we use the term provider to include a doctor, hospital,
health care professional, and health care facility, and their billing
staffs.

3U.S. General Accounting Office, Medicare: Communications with Physicians
Can Be Improved, GAO-02-249. Washington, D.C.: Feb. 27, 2002.

by physicians and other Part B providers. We compiled a group of 18
frequently asked questions (FAQ) from providers from a variety of
carriers' Web sites and asked CMS to review our questions. We solicited
this input to give CMS officials an opportunity to identify questions that
they considered to be an inappropriate question for our test. Based on
their comments, we decided to eliminate 3 questions that they considered
problematic. For example, we eliminated 1 question that involved a matter
that they said was the subject of an ongoing lawsuit. We then chose 4 of
the 15 remaining questions to use during our 300 test calls. These
questions addressed (1) billing for beneficiaries transferred from one
hospital to another, (2) billing for services delivered by therapy
students, (3) billing for multiple surgeries for the same patient on the
same day, and (4) billing for an office visit and procedure for the same
patient on the same day. We classified responses in three categories:
correct and complete, partially correct or incomplete, and incorrect.4 CMS
officials validated our assessments of whether responses were correct and
complete. To evaluate CMS's efforts to enhance communications with
providers, we conducted site visits to two carrier call centers where we
observed CSRs responding to callers' questions. We also reviewed materials
related to CMS's two ongoing initiatives to improve the accessibility of
information, including the development of a computer application to
increase accessibility of claims related information at carrier call
centers. One of the call centers we visited was responsible for pilot
testing this new application, and we observed a CSR demonstrating how it
would be used. We also reviewed the agency's other key effort to improve
access to policy-oriented information-the publication of clarifications
regarding new policies that affect providers. Finally, we interviewed CMS
and carrier officials familiar with these initiatives.

To evaluate CMS's efforts to provide oversight of carrier call centers, we
reviewed CMS's protocols for CPEs of carrier call centers as well as

4We defined a correct and complete response as an answer that provided
enough information to correctly bill Medicare, including (1) a correct
explanation of how to apply the billing policy and (2) correct billing
codes or a referral to specific documentation that provided coding
information. A partially correct or incomplete response contained an
answer that provided some explanation, but (1) did not provide assistance
in interpretation or warn about special circumstances that would affect
billing; (2) provided interpretation but no directions to specific
documentation; or (3) was correct, but not sufficiently complete to ensure
that the claim would consistently pass claims processing edits. We defined
an incorrect response as an answer containing fully or partially incorrect
information, such that a physician might incorrectly bill or not file a
claim for a billable service. For more detailed information on our scope
and methodology, see app. I.

  Results in Brief

reports for CPEs performed in fiscal years 2001 and 2002. In addition,
during our site visits to carrier call centers we observed supervisory
monitoring of CSRs' conversations with providers for quality purposes. We
also observed CMS regional staff demonstrate the use of the agency's new
remote monitoring capabilities, which enable CMS staff in their own
regional offices to listen to CSRs' conversations with callers. Appendix I
contains more information about the scope and methodology of our work. The
specific questions we posed to call centers and the correct answers are
contained in appendix II. We performed our work from September 2003
through June 2004 in accordance with generally accepted government
auditing standards.

During our test calls, CSRs typically provided incorrect and incomplete
answers to the 300 policy-oriented questions we posed. Only 4 percent-or
12-of their responses were correct and complete. Our test suggested
several factors that may account for poor performance, including the
fragmented array of information available to CSRs, confusing policy
information, as well as difficulties in retaining CSRs. Although CMS is
currently implementing two initiatives that may improve CSRs' access to
information, neither of these new tools is designed to support the CSRs'
responding to providers' policy-oriented questions.

CMS requires carriers to monitor the performance of their call centers,
but these monitoring activities do not effectively evaluate the accuracy
and completeness of CSRs' responses to policy-oriented questions. Neither
the standards used by the carriers to evaluate the CSRs' performance nor
the technological resources used in the evaluations are adequate to assess
whether the responses are correct. Similarly, monitoring performed by CMS
does not provide a method to evaluate CSRs' performance. CMS's periodic
CPEs focus more on the procedural, rather than the substantive, components
of a call-for example, how long callers are kept on hold rather than
whether questions were answered correctly. Moreover, in the last 2 years
only one carrier call center has been the subject of such an evaluation.
And while CMS has developed a new capacity to remotely listen to calls
placed to carrier call centers, agency staff are unable to fully assess
whether CSRs are providing callers with correct and complete answers
because they cannot view the material accessed by the CSRs during these
calls.

We are making recommendations to the CMS administrator to (1) create a
process to routinely screen calls and route complex policy inquiries to
staff with expertise; (2) develop policy-oriented information that is
easily

available to CSRs in a clear and understandable format; and (3) establish
an effective monitoring program for carrier call centers to assess CSRs'
performance. CMS generally agreed with our recommendations.

                                   Background

CMS develops regulations and policies to implement the statutory
provisions governing the Medicare program, and it communicates the
information to providers primarily through its Medicare contractors. The
contractors share information with providers through their Web sites,
written bulletins, and carrier call centers. To respond to inquiries from
providers, carriers operate 34 call centers.5 Most of the carrier call
centers-31 of 34-are "blended," that is they respond to inquiries from
beneficiaries as well as from providers. In most cases, CSRs at "blended"
call centers answer calls from both providers and beneficiaries.6

More than 21 million inquiries were made to carrier call centers in fiscal
year 2003. The vast majority of these were "status-oriented" calls.
Typically status-oriented calls are relatively simple to answer and
involve inquiries concerning the status of a claim or confirmation of an
individual's eligibility for Medicare. Such calls generally do not require
CSRs to provide callers with complex information. On the other end of the
spectrum are "policy-oriented" questions, which involve more complicated
issues, such as billing rules, covered services, and medical policies. The
remaining calls include elements of both status-oriented and
policyoriented inquiries. For example, a provider may call to learn why a
claim was denied. In some instances, the explanation may be simple, such
as the claim form omitted necessary information. In others, the reason for
the denial may be more complex and involve an assessment of whether the
particular circumstance required to obtain Medicare payment was met.
Although CMS requires that carriers report data that categorize calls by
type, these categories are not standardized, and carriers differ in the

5CMS has also established beneficiary toll-free telephone lines at six
other call centers to handle beneficiaries' inquiries about the program.
These centers are referred to as 1-800-MEDICARE call centers. These six
centers are operated by a special contractor that is neither a carrier nor
a fiscal intermediary. CMS reports that in 2003 CSRs in these centers
responded to almost 6 million calls regarding topics such as Medicare
enrollment and coverage; replacement of Medicare identification cards; and
available health plan options, such as traditional fee for service,
preferred provider organizations, and health maintenance organizations.

6Beginning October 1, 2005, CMS will require all "blended" call centers to
have CSRs that are dedicated to responding to provider inquiries.

criteria they use to define call type. CMS officials estimate the volume
of calls received by CSRs involving policy-oriented questions to have been
approximately 500,000 in fiscal year 2003.

In fiscal year 2001, CMS required that all carrier call centers install
automated voice response systems. The interactive voice response (IVR)
unit allows providers to use their telephone keypads to respond to
automated prompts and obtain status-oriented information without speaking
to CSRs. Use of the IVR has been growing, and in fiscal year 2003, the
automated system handled more than 52 percent of provider inquiries
answered at carrier call centers. CSRs are available to respond to
inquiries that providers believe are beyond the capability of the IVR,
including policy-oriented calls. Generally, calls to CSRs are
electronically routed by the carriers' automated systems based on CSR
availability. The routing process does not consider the nature and
complexity of the question or the expertise of the CSRs. Despite the
diversion of many calls to the IVR, CSRs recently experienced an increase
in the number of calls that they answer. According to CMS, the number of
calls CSRs answered increased from 9 million in fiscal year 2002 to 10
million in fiscal year 2003.

CSRs responding to status-oriented calls can typically access the relevant
claims or enrollment information to respond to the inquiry. In addition,
to assist CSRs, carriers have developed scripted responses to answer
standard questions from beneficiaries, such as how to enroll in Medicare.
To respond to inquiries from providers, CSRs may use FAQs posted on their
carriers' Web sites. In addition, they may search a variety of other
sources, including CMS's Web sites. If CSRs cannot locate information to
respond to a provider's question, they may arrange to contact the
provider-after conferring with a specialist.

In addition, CMS requires each carrier to analyze provider inquiry data
and develop a list of questions most frequently asked and areas of concern
or confusion for providers. They must also tally problem areas identified
when providers submit erroneous claims for payment. Each quarter, carriers
report the 10 most frequent inquiries and claim submission errors to CMS
and update the list of FAQs on their own Web sites. Because the nature of
calls may vary by carrier, the types of questions posted on these Web
sites may also vary. In addition, some carrier Web sites only list FAQs
that are policy related, while others list routine questions about the
mechanics of claims submissions and correcting billing errors.

Carriers are required to monitor their own call centers and report to CMS
on their performance, such as the average time that calls wait before
being

connected to a CSR and the percentage of provider calls that are abandoned
before they reach a CSR. Carriers are also required to listen to, and
rate, a selection of CSR calls on customer and knowledge skills, such as
the manner in which they greet callers, conduct the call, offer additional
assistance at the conclusion of the call, and whether their responses are
correct and complete. Through CPEs, CMS also evaluates call center
compliance with performance measures it establishes. Recently, CMS piloted
remote call monitoring, which allows CMS staff to listen in on provider
calls.

CMS's administration of the Medicare program will undergo significant
changes over the next several years as the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA) is implemented. MMA
provides CMS with increased flexibility in contracting with new entities
to assist it in operating the Medicare program.7 Instead of primarily
relying on the claims administration contractors to perform most of the
key business functions8 of the program, the law authorizes CMS to enlist a
variety of contractors to perform these tasks. For example, the MMA will
allow CMS to use new contractors to communicate program information to its
providers and deliver provider education and training. CMS is just
beginning to develop plans to implement MMA's contracting reform
provisions. Phase-in of certain provisions may begin as early as October
2005, and all carrier and fiscal intermediary contracts are scheduled to
end by October 1, 2011. After this date, new contracts must be based on
CMS's new authority. The agency expects to issue its implementation plan
for contracting by October 1, 2004.

CSRs at the carrier call centers we tested rarely provided correct and
complete answers to our policy-oriented questions. Only 4 percent of the
responses we received from CSRs were correct and complete. Our test
suggested several factors that may account for poor performance, including
fragmented information scattered among a variety of sources, confusing
information that may be difficult for CSRs to understand and interpret,
and difficulties in retaining CSRs. CMS is developing two

  CSRs' Responses to Policy-Oriented Questions Were Largely Incorrect

7Pub. L. No. 108-173, S: 911(a)(1), 117 Stat. 2066, 2378-2386 (to be
codified at 42 U.S.C. S:1395kk-1 note).

8There are nine key business functions: claims processing, beneficiary and
provider customer service, appeals, provider education, financial
management, provider enrollment, reimbursement, payment safeguards, and
information systems security.

initiatives that may improve CSRs' access to information; however, neither
of these new tools is designed to provide a comprehensive source of
information to support the CSRs who respond to providers' policyoriented
questions.

    CSRs Almost Never Provided Correct and Complete Responses to Our Policy
    Questions

We found that CSRs provided incorrect, partially correct, or incomplete
responses to 96 percent of the 300 policy-oriented test calls we made to
carrier call centers. The four questions we posed concerned a variety of
circumstances on the proper way to bill Medicare in order to be paid for
services rendered. Our questions specifically addressed the following
topics: billing for beneficiaries transferred from one hospital to
another, billing for services delivered by therapy students, billing for
multiple surgeries on the same day, and billing for an office visit and
services on the same day. The results of our test, which CMS Medicare
coding and policy experts validated, are shown in table 1.

           Table 1: Summary of Accuracy of CSR Responses by Question

                                   Correct and  Partially           
                                               correct or           
              Question             complete    incomplete Incorrect     Total 
                                   response      response response  responses 
             Question 1:                                            
      Billing for beneficiaries                                     
             transferred                                            
    from one hospital to another             2         22        51 
             Question 2:                                            
Billing for services delivered                                   
                 by                                                 
          therapy students                   5         32        38 
             Question 3:                                            
    Billing of multiple surgeries                                   
               for the                                              
    same patient on the same day             1         36        38 
             Question 4:                                            
Billing of an office visit and                                   
              procedure                                             
     for the same patient on the             4         35        36 
              same day                                              
    Number of carrier call center                                   
              responses                     12        125       163 
     Percentage of carrier call                                     
               center                                               
              responses                      4         42        54       100 

Source: GAO analysis of CSR call center responses.

Notes: CMS officials validated responses for correctness and completeness.
Differences between GAO and CMS assessments were reconciled.

    Variety of Factors Contributed to CSRs' Incorrect and Incomplete Responses

Our analysis of CSR responses to test questions and discussions with CMS
officials identified several factors that contributed to CSRs' errors.
They include the following:

Fragmentation of information: When responding to Medicare inquires from
providers, CSRs rely on fragments of information from multiple electronic
sources. In addition, many CSRs use printed Medicare program information,
including policy changes, which CMS estimates at about 200 per year. For
example, at one carrier call center, we observed that CSRs relied on
electronic information from CMS and carrier Web sites, along with paper
documents, including the Medicare carrier manual, program memorandums, and
carrier bulletins. Further, CMS officials told us that the agency does not
prepare scripted responses to follow when answering questions from
providers as it does for CSRs responding to beneficiaries' inquiries.

During the site visit, we also asked one CSR to demonstrate the process
that would typically be followed to answer our four policy-oriented
questions. In responding to one of our questions, we observed that this
CSR did not have a source of comprehensive information that she could
easily access to find the answer to our question. Instead, she accessed
multiple information sources, including both electronic materials and
paper documents, in an attempt to respond to our question. We further
noted, as we toured the call center, that other CSRs also had access to,
and appeared to be using, both paper and automated resources as they
responded to calls. According to CMS and carrier officials, CSRs have to
learn to operate multiple information systems, including CMS's claims
information processing system and carrier developed information system.
They also must access other sources, such as carrier or CMS Web sites, to
respond to policy-oriented questions. Although CMS required that all CSRs
have access to the Internet in fiscal year 2003, some CSRs continue to
rely heavily on paper documents because of their familiarity with these
materials.

During our 300 test calls, CSRs referred us to a total of 13 different
information sources when answering our second question regarding billing
for services delivered by therapy students. Twelve of the references were
either incorrect or did not include all of the information needed to give
a correct and complete answer. Our review of the 13th document, which was
structured in a question and answer format, included our specific test
question but without the complete answer. Fragments of the answer,
however, were located earlier in the document. We also found other parts
of this answer on a different page, attached to a different but related

question. It was evident to us that without reading the entire document,
it would be plausible for the CSR to have read the test question and
mistakenly given the caller the wrong answer, while assuming that the
response given was correct and complete.

Confusing information: Some of the information that CSRs must access to
respond to policy-oriented questions is difficult to interpret. CMS
officials acknowledged that some policies contain complex language. In
addition, they told us that the agency's goal of quickly publishing a
policy that is technically correct may sometimes overshadow its effort to
develop a clear and understandable document. For example, we identified
confusion among CSRs who responded to our second question concerning
billing for services delivered by therapy students. Based on their exact
responses, we were able to determine that 12 percent of the incorrect
responses to this question were caused by the CSRs' confusion over a
different Medicare policy, regarding the billing for services delegated by
one professional provider to another, and not a student.

CMS acknowledges that specialized training is required to understand the
billing codes and modifiers9 that providers must include on their claims
forms to receive payment from the program. Although CMS requires carriers
to train CSRs, the agency has determined that answering providers' coding
questions about specific claims is beyond the scope of CSRs'
responsibilities. CMS also indicated that CSRs do not have the expertise
to instruct a provider on the nuances of coding a service. CSRs, however,
are permitted to respond to general questions about codes and modifiers,
including coding definitions and explanations regarding the appropriate
use of modifiers. We identified confusion among CSRs when they responded
to such questions. In response to two of the four questions we posed, CSRs
should have included specific modifiers with their answers because our
questions were general and did not involve specific claims information.
However, CSRs provided specific modifiers in only 16 of the 150 responses
to these two questions. And, in most of these instances-9 of 16-the
modifiers they cited were incorrect. For example, in one of our test
questions, we asked for the extenuating circumstances for which carriers
may pay the full amount for a second surgical procedure. In eight of the
calls, CSRs responded that the provider should

9Modifiers provide a means by which a reporting physician can indicate
that a service or procedure that has been performed has been altered by
some specific circumstance but not changed in its definition or code.

use either modifier "51" for multiple surgeries on the same day, modifier
"59" denoting a distinct surgical procedure, modifier "58" for a staged
procedure, modifier "76" indicating that a procedure was repeated by the
same physician, or modifier "78" for a return to the operating room for a
related procedure. The correct answer is modifier "22," indicating that
the service performed was an unusual procedure. Without the correct
modifier, the claim could be inappropriately denied or improperly paid.

In addition, according to one CMS Medicare official-and confirmed by CSRs'
responses to our test questions-CSRs may gravitate toward generic
explanations and apply them to questions, even when they are not specific.
For example, when answering our third question regarding billing for
multiple surgeries to the same patient on the same day, 56 percent of the
CSRs failed to address the extenuating circumstances in which a provider
would be paid for multiple surgeries. Instead, their responses were based
on their knowledge of general multiple surgery payment rules, which
indicate that Medicare will pay 100 percent of costs for a beneficiary's
first surgery and a reduced percentage for the second surgery. In
addition, we categorized about 15 percent of CSRs' answers to our 300 test
questions as vague and nonresponsive because, in these instances, CSRs
simply responded that Medicare services must be medically necessary or
that they cannot be preapproved. Although the vague answers may be
correct, the responses did not address the specific elements contained in
our questions.

Difficulties in retaining CSRs: Difficulties in retaining staff limits
carriers' ability to maintain a core of CSRs who are proficient on a range
of complex, policy-oriented issues. CMS officials told us that retaining
CSRs has been a major staffing problem. According to CMS officials, many
of the most qualified CSRs are promoted to different positions within the
call centers or resign to pursue better opportunities elsewhere. An
internal CMS study found the turnover rate for carrier call center CSRs to
be as high as 23 percent from calendar years 1999 through 2001 for all
carrier call centers. This is significantly higher than the attrition rate
for CMS's call centers for beneficiaries, 1-800-MEDICARE help lines, which
one CMS official estimates is close to industry standards-about 10
percent. Although there are no more recent data, CMS officials view this
as troubling. They explained that the CSR position is particularly
challenging because, in addition to learning how to access and utilize
multiple information systems, these employees must stay abreast of
Medicare policy changes to answer the broad range of inquiries received by
the carrier call centers.

    CMS's Efforts Not Targeted to Supplying Policy-Oriented Information to CSRs

Although CMS is currently implementing two initiatives that may improve
CSRs' access to information, neither of these new tools is designed to
support the CSRs who respond to providers' policy-oriented questions. One
is intended to enhance CSRs' accessibility to claims information; the
other is aimed at clarifying information on new Medicare policies.

First, CMS has begun deployment of a new computer application, Next
Generation Desktop (NGD), to provide a single source of consolidated
claims and related information to assist CSRs when they respond to
statusoriented questions. Although NGD also contains some policy-oriented
information, such as scripted responses for CSRs who respond to questions
from beneficiaries, it does not improve CSRs' ability to respond to
policy-oriented questions from providers. Recognizing the broader range of
issues and the relative complexity of provider inquiries, CMS officials
have not attempted to develop scripted responses to such questions.
Although CMS is continuing to study the role of NGD in providing
policy-oriented information, agency officials told us they are uncertain
whether NGD is the appropriate mechanism to enhance the availability of
such information to CSRs. Until CMS makes a final determination, CSRs can
continue to access policy-oriented information on the agency's Web site.

Second, CMS has developed a new strategy to clarify Medicare policy for
providers, which CMS officials told us will also benefit the CSRs who
respond to provider questions. CMS has retained a consulting firm to write
explanatory articles about new Medicare policies. Although these articles
may educate providers, they will be no more accessible to CSRs than the
existing array of materials. For example, these articles are available to
CSRs through CMS's Web site and carriers' Web-based bulletins. Although
these articles contain citations to regulations and laws, for example,
they are not electronically linked to the policies they describe. In
addition, the policies they support are not annotated to reflect that an
article exists, making it unlikely that CSRs can easily locate the
clarifying information. Moreover, there are no plans to publish articles
for the majority of existing policies.

Like CMS-sponsored call centers, there are thousands of other call centers
serving a large range of businesses and government agencies in the United
States. Many of these centers rely on IVRs to route calls to the next
available CSR. Other call centers have implemented systems that are more
advanced than those used by carriers. Many of these centers triage
incoming calls through a feature known as "skill-based routing."
Skillbased routing systems are designed to enhance customer service by

allowing the call center to first identify the nature of an incoming call
and to then distribute the call to the CSR who is best qualified to
respond to the caller's question. CSRs working in a skill-based routing
environment develop expertise in key specialty areas so they can quickly
and knowledgably respond to callers' questions. Although CMS has indicated
it is committed to improving communications with providers, it has not
taken steps that would enable it to identify the subject of providers'
policyoriented questions and route their calls to the most appropriate
CSRs.

CMS requires carriers to monitor the performance of their call centers.
However, the performance standards that carriers are required to use, and
the technology available to most of them, do not facilitate thorough
assessments of whether CSRs provide correct and complete responses to
policy-oriented questions. In addition, CMS's own monitoring efforts- CPEs
and remote monitoring of select calls-do not provide sufficiently detailed
or meaningful information regarding CSR accuracy.

  Call Center Oversight Does Not Adequately Assess CSRs' Responses to
  Policy-Oriented Questions

    Carrier Self-Monitoring Does Not Effectively Evaluate CSRs' Responses to
    Policy-Oriented Questions

CMS does not require carriers to monitor a sufficient number of calls to
fully evaluate the CSRs' performance. CMS requires carriers to monitor
their own call center performance by periodically listening to, and
rating, a sample of each CSR's calls. On average, each CSR answers more
than 1,700 calls a month. In fiscal year 2004, CMS required carriers to
evaluate three calls per CSR per month. Furthermore, for the 31 "blended"
call centers, which respond to inquiries from both providers and
beneficiaries, carriers are only required to monitor one provider call per
CSR per month. This falls short of one call center industry expert's
recommendation to monitor a minimum of eight provider calls per CSR per
month to obtain accurate statistics on CSR performance.10 It is also lower
than the most frequent monitoring of calls per month from a survey of 735
North American call centers that represent help lines in various
industries, including telecommunications, financial services, and health
care.11 According to this study, there is a wide variance in the number of
calls monitored per month per CSR. However, the most commonly reported

10The expert is the director of a university-based center for benchmarking
the performance of call centers and was a featured speaker at CMS's 2001
Telephone Customer Service Conference.

11Incoming Calls Management Institute, Call Center Monitoring Study II
Final Report. (Annapolis, Md.: 2002).

monthly monitoring frequencies by survey respondents were 4 to 5 and 10 or
more-exceeding CMS's requirement.

In addition, CMS-developed quality standards used by carriers to conduct
self-monitoring do not measure CSR performance in a meaningful way. CMS
requires that CSRs be evaluated on customer skills-such as vocal tone,
volume and politeness-and knowledge skills-including the accuracy and
completeness of responses. However, we reported in 2002 that CMS's
definition of what constitutes accuracy is neither clear nor specific. For
example, according to CMS's standards, carriers should consider a response
"accurate" if the CSR "gives an accurate response or referral" as opposed
to providing necessary and complete information for the provider to bill
the program correctly. Without such guidance or other criteria linked to
measurable outcomes, the carrier has little basis to evaluate the
correctness and completeness of CSRs' responses to policyoriented
questions. Although we recommended that CMS establish new performance
standards for CSRs that emphasize providing correct and complete answers
to provider inquiries, CMS has not revised the definition.

Moreover, CMS has not instituted standard requirements for the technology
used by carriers when conducting self-monitoring activities. As a result,
there is a broad range of self-monitoring capabilities among the carriers,
which, according to CMS officials, can affect a supervisor's ability to
determine whether a CSR's response was correct and complete. For example,
only 14 of the 34 carrier call centers have the capability of recording
both the audio portion of monitored calls and the associated computer
screens viewed by CSRs. This technology enables the supervisors monitoring
calls to follow the actions taken by CSRs, step by step, as they respond
to callers. Not only can these supervisors hear callers' questions and
CSRs responses, but they can also view every computer screen accessed by
CSRs during calls, enhancing their ability to determine whether CSRs
supplied answers that were correct and complete. However, the remaining 20
call centers do not have this capability. While supervisors at 17 of them
can record the audio portion of calls, they cannot view the computer
screens accessed by the CSRs. Supervisors at 3 centers have no recording
capability and are limited to listening to and evaluating "live" calls as
they are received.

    CMS Does Not Adequately Evaluate CSRs' Responses to Policy-Oriented
    Questions

Although CMS's principal oversight tools-CPEs-are designed to evaluate
call centers' compliance with performance standards, they do not provide a
comprehensive assessment of whether information provided by CSRs is
correct and complete. As we noted in our previous report, these on-site
evaluations, which are conducted by CMS staff and follow a structured
protocol, focus on performance standards that address procedures. For
example, in preparing that report, we observed a CPE review team
concentrated on procedural items such as how long a caller was kept on
hold, rather than on whether the information provided was correct and
complete. Although CPE evaluators also review call center data and
interview call center managers, these activities do not provide a method
to measure the correctness and completeness of CSR responses.

We found that the CPE evaluation criteria are not designed to verify that
CSRs' responses to providers are accurate. Instead, they focus on
evaluating whether carriers are appropriately adhering to CMS's
selfmonitoring requirements. For example, the CPE evaluators listen to a
sample of calls self-monitored by the carrier to verify that the carrier
is properly evaluating and documenting the CSRs' performance. In listening
to these sampled calls, the CPE evaluators are not required to evaluate
the correctness or completeness of responses provided by a CSR, rather
they are expected to ensure that the carrier has a system in place to
monitor calls. Although our earlier report included a recommendation that
CMS employ expert teams to conduct more substantive reviews of calls to
strengthen CPEs, CMS told us at that time that this was not feasible. CMS
officials recently told us, however, that in many instances, CPE
evaluators do not have the expertise to evaluate the accuracy of CSRs'
responses.

In addition, CPEs are not performed often enough to provide current
feedback on either call center or CSR performance. In fiscal year 2002,
only one carrier call center had a CPE covering provider telephone
inquiries. Not one CPE was performed in fiscal year 2003. We also found
that CPEs are based on an assessment of too few calls to provide
meaningful data and are conducted too infrequently to provide current
information on call center performance. The required CPE sample is too
small to provide reliable results. CPE evaluators listen to a sample of 10
calls monitored by the carrier. If the call center is "blended"-as 31 of
the 34 are-the CPE evaluators will listen to 5 provider calls. As a point
of comparison, if a call center with the smallest number of CSRs monitors
216 provider calls from its CSRs annually, we found that CPE evaluators
would have to draw a simple random sample of 138 provider calls annually
to estimate the percentage of correct and complete calls within a margin
of error of plus or minus 5 percent, with a 95 percent confidence level.

CPE evaluators monitoring a call center with a larger number of CSRs would
have to conduct more monitoring. For example, a call center that monitors
1,800 provider calls from its CSRs annually, would require the CPE
evaluators to draw a simple random sample of 317 provider calls annually
to reach this same confidence level.12

In July 2003, CMS introduced a pilot project that provides a second means
of monitoring carrier call centers. CMS can now remotely monitor calls by
dialing into carrier call centers and listening to calls as they occur.
Remote monitoring provides CMS with an opportunity to hear providers'
questions, as well as CSRs' responses, firsthand. Initially, CMS staff
listened to 10 calls per month for each center, to develop a general
understanding of provider inquiries and to contribute to developing the
strategy for future monitoring. However, the staff responsible for remote
monitoring reported being overwhelmed by the burden inherent in the task,
and in January 2004, CMS reduced the number to five calls per center per
month. Staff engaged in remote monitoring can only access the audio
portion of calls, limiting their ability to thoroughly evaluate the
correctness and completeness of CSRs' responses. In addition, CMS
officials recognize that like CPE evaluators, staff engaged in remote
monitoring lack the necessary understanding of substantive policy issues
involved in the call to determine whether CSR responses were correct.
Agency officials stated that they are studying how to best make use of
this new capability. They told us that they are uncertain whether the
pilot project will be expanded because they are not convinced that remote
monitoring is the most appropriate vehicle for evaluating the correctness
and completeness of CSR responses to provider questions.

Conclusions 	Ensuring that physicians and other providers receive correct
and complete answers to their policy-oriented questions is critical to
their ability to correctly bill Medicare for services rendered to the
program's beneficiaries. Although policy-oriented questions may represent
a small proportion of inquiries made to call centers, it is nonetheless
important to ensure that providers can rely on the information they
receive. Many call centers serving a variety of businesses have taken
advantage of skill-based

12We based this analysis on the number of CSR full-time equivalents for
carrier call centers in fiscal year 2003, which ranged from 6 to 55.
Carriers are expected to monitor three calls per CSR per month. As a
result, depending on the number of full-time equivalents for each call
center, carriers would be expected to have monitored from 216 to 1,980
calls during fiscal year 2003.

routing to identify a caller's specific question and direct the call to
the CSR most qualified to respond. However, CMS has not done so, nor has
it developed other strategies to improve the ability of CSRs to respond to
inquiries from providers. Our test calls continue to show that carrier
call centers do not adequately respond to policy-oriented questions. When
responding to our questions, it was evident that CSRs lacked access to
comprehensive materials that would facilitate correct and complete
answers. Instead, CSRs relied on fragmented information sources and were
also confused about Medicare policy issues. Furthermore, while CMS is
attempting to enhance its monitoring efforts, it has not established a
program that can sufficiently evaluate whether providers receive correct
and complete answers to their policy-oriented questions. Now that CMS has
been given new authority to contract with a variety of entities to assist
it with managing the Medicare program, it should take the opportunity to
improve its communications with providers. The new law gives CMS the
opportunity to identify organizations that can best assist it with
developing policy expertise among staff who respond to providers'
questions, improving access to policy-oriented materials, and enhancing
call center monitoring.

Recommendations for 	In order to improve the accuracy and completeness of
responses to policyoriented inquiries from providers, we recommend that
the Administrator

Executive Action 	of CMS take steps to ensure that all CSRs have the
necessary tools to respond to such calls. Specifically, we recommend that
the Administrator take the following three actions:

o  	Create a process to routinely screen and triage calls by routing
complex policy-oriented questions to staff with the expertise to
adequately address them.

o  	Develop clear and easily accessible policy-oriented materials to
assist CSRs. The materials should be electronically searchable so that
CSRs can expeditiously provide correct and complete responses to
policy-oriented questions.

o  	Establish an effective monitoring program for call centers to assess
CSRs' performance. The program should include the development of specific
performance standards that will allow CMS to thoroughly and routinely
measure the correctness and completeness of information given by CSRs in
response to policy-oriented questions.

  Agency Comments

In written comments on a draft of this report, CMS expressed its
commitment to improving communications with providers and generally agreed
with our recommendations. CMS agreed with our first recommendation to
create a process to routinely screen and triage calls. CMS said it plans
to establish a tiered system using specialty staff to respond to provider
inquiries by fiscal year 2005. CMS also agreed with our second
recommendation that clear and easily accessible policy-oriented materials
should be available and electronically searchable for CSRs. However, they
went further to state that clear and accessible information will also be
available to specialty staff tasked with responding to complex
policy-oriented questions. CMS also described its efforts to make
information available to providers through customized Web pages and other
educational materials. While CMS agreed with the concept of establishing
an effective monitoring program-our third recommendation-it stated that it
is in the process of determining how to do so once its new approach of
triaging calls is implemented. CMS also said it is exploring other
initiatives to enhance monitoring such as modifying its CPE requirements,
developing performance-based standards for provider telephone inquiries,
and surveying providers on their satisfaction with call centers'
performance.

We have reprinted CMS's letter in appendix III. CMS also provided us with
technical comments, which we have incorporated as appropriate.

As agreed with your office, unless you announce its contents earlier, we
plan no further distribution of this report until 30 days after its
issuance. At that time, we will send copies to the Administrator of CMS
and other interested parties. We will then make copies available to others
upon request. In addition, the report will be available at no charge on
GAO's Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at (312) 220-7600. An additional GAO contact and other staff who made
contributions to this report are listed in appendix IV.

Sincerely yours,

Leslie G. Aronovitz Director, Health Care-Program Administration and
Integrity Issues

                       Appendix I: Scope and Methodology

To determine carriers' effectiveness in providing correct and complete
responses, we placed 300 calls to 34 carrier call centers. We searched a
variety of carriers' Web sites and compiled a group of 18 questions that
physicians and other Part B providers frequently asked when contacting
call centers. The questions represented common, policy-oriented questions
concerning the proper way to bill Medicare in order to obtain payment from
the program, as opposed to status-oriented claims inquiries. We asked
Center for Medicare & Medicaid Services (CMS) officials to review our
questions to determine whether they considered any of the 18 questions
inappropriate for our test calls. For example, we did not want to pose a
question that would unfairly test a customer service representative (CSR)
knowledge and thus we did not want to include a question on a new or
recently changed policy. We also did not want to pose questions that were
the subject of an ongoing controversy. Based on input from CMS officials,
we eliminated three questions. The first question we eliminated referred
to pricing rules for multiple surgeries. CMS officials stated that the
response to this question, as posted on a carrier's Web site, was unclear.
The second question we excluded referred to reimbursements for nurse
practitioner services. CMS officials also expressed hesitancy about the
phrasing of this question and answer as shown on a carrier's Web site.
Although CMS ultimately suggested language to rephrase this question and
answer, we opted to remove the question from consideration. The third
question we eliminated referred to an issue that CMS officials told us was
the subject of an ongoing lawsuit.

After obtaining CMS's input, we selected 4 questions (see app. II) from
the remaining 15 questions. These questions addressed: (1) billing for
beneficiaries transferred from one hospital to another, (2) billing for
services delivered by therapy students, (3) billing for multiple surgeries
for the same patient on the same day, and (4) billing for an office visit
and procedure for the same patient on the same day. We did not inform CMS
before making the calls of the final questions we selected. Each of the
four questions was randomly assigned across the 34 carrier call centers
and each question was posed 75 times. Calls were placed at different times
of day and different days of the week from October 20 through November 3,
2003. Twenty-eight of the carrier call centers were called nine times and
the remaining six call centers were each called eight times.

To facilitate our calls, CMS officials informed call center managers of
our test. They also agreed not to disclose any of the potential questions
to carrier call center staff. During our calls, we identified ourselves as
GAO representatives and asked each CSR to answer our question as if we
were providers. To prevent us from biasing CSRs' responses and to ensure

Appendix I: Scope and Methodology

fairness, we read each question to CSRs without offering additional
information or explanations. However, we repeated questions upon request.
Prompts were only given if the CSR probed for more specific information or
gave conditional responses that depended upon different circumstances. In
those situations, we asked the CSR to provide the correct answer for each
set of circumstances. Following the response, we asked the CSR if there
was any additional information he or she would like to provide. We also
told CSRs we were manually recording their responses verbatim. We analyzed
the CSR responses and simultaneously submitted them to Medicare coding
experts at CMS. Our assessment of CSR responses and the coding experts'
verification of results relied on the following criteria:

o  	Correct and complete: The answer provided enough information to
correctly bill the Medicare program, including (1) a correct explanation
of how to apply the billing policy and (2) correct billing codes or a
referral to specific documentation that provided coding information.

o  	Partially correct or incomplete: The answer provided some explanation,
but (1) did not provide assistance in interpretation or warn about special
circumstances that would affect billing; (2) provided interpretation but
no directions to specific documentation; or (3) was correct, but not
sufficiently complete to ensure that the claim would consistently pass
claims processing edits.

o  	Incorrect: The answer contained fully or partially incorrect
information, such that a physician might incorrectly bill or not file a
claim for a billable service.

Following CMS's verification, we discussed and resolved all discrepancies
between our assessment of responses and CMS's verification. For example,
when initially assessing CSRs' responses, we attempted to locate Web site
documents that CSRs referred to during our call. If we found that the
reference contained all the accurate information necessary to bill the
program properly, we considered the CSRs' responses to be correct and
complete even if they did not tell us the information themselves. Although
CMS coding experts did not initially review these documents, and therefore
may have considered the CSR's response to be incorrect and incomplete,
they subsequently agreed that this was a fair and appropriate criterion to
add to our assessment.

The results from our 300 test calls are limited only to those calls and
are not generalizable to the population of calls routinely made to call
centers by providers. Although the four policy-oriented questions we posed
were

Appendix I: Scope and Methodology

frequently asked questions obtained from carrier Web sites, they do not
encompass all of the questions that providers might ask.

We also interviewed carrier and CMS officials to determine what efforts
the agency had in place to enhance CSRs' access to information. We
reviewed information regarding the Next Generation Desktop (NGD)
application, including videotape and internal documents outlining the
phase-in schedule for the application. In addition, we observed a
demonstration of the NGD application and monitored its capability to
facilitate CSR's responses to providers' questions.

To determine the efforts CMS has made to provide oversight, we identified
CMS requirements for carrier call center operations and discussed with CMS
staff the agency's oversight and monitoring of carrier call center
activities. We reviewed the agency's protocol for its contractor
performance evaluations (CPE) to determine the scope of work evaluators
would perform and evaluated carrier call center performance standards to
identify the types of problems found during their site visits. We also
reviewed CPE reports from fiscal years 2001 and 2002. CMS did not perform
any CPEs in fiscal year 2003. We visited two carrier call centers and
consulted an industry expert on issues related to call center technology
and standards. In addition, we observed carrier call centers' monitoring
of calls for quality at one of the carrier call centers we visited. We
also observed CMS regional staff performing remote monitoring of provider
calls. We performed our work from September 2003 through June 2004 in
accordance with generally accepted government auditing standards.

Appendix II: Carrier Call Center Accuracy Test Questions

The questions and answers we used to test the accuracy of carrier call
center responses to policy-oriented questions are shown in table 2.

        Table 2: Questions and Answers for Test of Carrier Call Centers

GAO question Question from carriers' Web sites Answer from carriers' Web
sites

Question 1: Billing for If Dr. Smith transfers a patient from hospital A
to beneficiaries transferred from hospital B for treatment, will Medicare
pay Dr. one hospital to another Smith for both the hospital discharge day

management services at hospital A and hospital

admission at hospital B?

Question 2: Billing for services The Current Procedural Terminology, or
CPT, delivered by therapy students codes for therapeutic procedure state,
the Physicians may bill both the hospital discharge management code and an
initial hospital care code when the discharge and admission do not occur
on the same day if the transfer is between (1) different hospitals, (2)
different facilities under common ownership which do not have merged
records, or (3) between the acute care hospital and a PPSa exempt unit
within the same hospital when there are no merged records. In all other
transfer circumstances, the physician should bill only the appropriate
level of subsequent hospital care for the date of transfer.

Medicare will pay for the one unit of direct services the therapist
provides to the patient under Medicare Part B. If the therapy student
assumes responsibility for treatment, the services are not payable under
Medicare Part B.

Note: However, if the qualified therapist maintains responsibility for the
service and one-on-one contact with the patient, the student may
participate at the direction of the therapist and Medicare will pay for
the service because it is provided by the therapist.

"physician or therapist are required to have direct, that is, one-on-one,
patient contact." What if the therapist, for example a PT, OT, or SLP,b
has some contact with the patient, say, 10 minutes direct patient contact
time, and then the student assumes responsibility for treatment under
supervision? Does Medicare cover that?

Question 3: Billing for multiple Are there any circumstances for which
carriers If a physician believes that extenuating

surgeries on the same day may pay the full amount for a second surgical
circumstances exist for performing multiple procedure performed by the
same physician on surgeries on the same day and that these the same day
but during a different operative surgeries should be paid at the full
amount, session? he or she may bill for the surgeries with modifier "22."
After reviewing the operative report, the carrier may determine that the
standard adjustment rules do not apply and pay "by report."

Appendix II: Carrier Call Center Accuracy Test Questions

GAO question Question from carriers' Web sites

Question 4: Billing for an office Will Medicare pay for a visit and a
procedure on visit and a procedure on the same the same day if reported by
the same physician day for the same patient?

Answer from carriers' Web sites

Medicare will not pay separately for a visit on the same day as a minor
surgery or endoscopic procedure unless other significant, separately
identifiable services are performed in addition to the procedure. The
payment amount for the procedure covers such pre- and postservice work as
record keeping, counseling, and prescribing recovery therapy.

However, if other significant evaluation and management services are
performed on the same day, the physician may bill for the visit with
modifier "25." In determining the level of visit to bill with the
modifier, physicians should consider only the content and time associated
with the separate evaluation and management service, not the content or
time of the procedure.

Visits that are related to a major surgery are not paid for separately if
reported by the same physician on the same day as the surgery. However,
the initial evaluation or consultation by the surgeon will be paid for
separately even if reported on the same day.

Source: Carrier Web sites

aPPS stands for prospective payment system.

bPT, OT, and SLP stand for physical therapist, occupational therapist, and
speech language pathologist, respectively.

Appendix III: Comments from the Centers for Medicare & Medicaid Services

Appendix III: Comments from the Centers for Medicare & Medicaid Services

Appendix III: Comments from the Centers for Medicare & Medicaid Services

Appendix III: Comments from the Centers for Medicare & Medicaid Services

Appendix III: Comments from the Centers for Medicare & Medicaid Services

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact Geraldine Redican-Bigott, (312) 220-7678

Acknowledgments 	Shaunessye Curry, Margaret Weber, Helen Chung, Mary
Reich, and Marie Stetser made key contributions to this report.

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