E/M Services Under the Gun ENSURE THAT YOUR CLIENTS ARE DOCUMENTING AND BILLING CORRECTLY Melody W. Mulaik, MSHS, RCC, PCS, CPC, CPC-H the January-February Billing magazine we discussed coding models that billing companies utilize to In serve their clients. There is always a fine line between providing services and helping to protect a client. In today’s environment I would argue that is it critical that third party billing companies provide more than just transactional services. You must seek to truly partner with your clients or risk losing them to another company that will. Partnering can mean a lot of different things, but at the end of the day, partners watch out for one another. For a billing company, this can mean staying alert to issues that impact their clients and keeping them apprised of potential areas of concern. one of the great areas of concern in today’s audit environment is the exponential increase in evaluation & management (e/m) audits. medicare recovery auditors (ras, formerly recovery audit contractors (racs)) have been tasked with the review of past claims for physician office visits, services that were previously off-limits for this type of review. recently the department of health and human services (dhhs) and the department of justice (doj) issued a letter stating that there were indications some health professionals were using electronic health record systems to clone medical record documentation on medicare claims to boost payments. an additional concern was upcoding the intensity of care provided or the patient condition. the letter, signed by secretary Kathleen sebelius and attorney general eric holder, states in part: a patient’s care information must be verified individually to ensure accuracy. it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments. according to an audit report (“coding trends of medicare evaluation and management services”) issued by the dhhs office of inspector general (oig) in may of 2012, medicare payments for e/m services increased by 48% between 2001 and 2010. the oig identified approximately 1,700 physicians who “consistently billed higher level e/m codes in 2010,” although their patients were similar to those of other physicians who billed for lower levels of service.1 the oig describes e/m services as “vulnerable to fraud and abuse.” the audit report states: in 2009, two health care entities paid over $10 million to settle allegations that they fraudulently billed medicare for e/m services. one health care entity allegedly billed medicare for higher levels of e/m services than were actually delivered to patients. in a separate case, a health care entity allegedly submitted false claims to medicare, which included e/m services as well as unnecessary home visits, tests, and procedures. in 2008, the centers for medicare & medicaid services (cms) found that certain e/m visit types had the most improper payments of all medicare Part b services. in 1983, cms adopted the cPt® coding system as part of the healthcare common Procedure coding system (hcPcs) and mandated that physicians use this system to bill e/m services. Physicians are responsible for billing the appropriate e/m code to medicare. it is inappropriate for a physician to bill a higher level, more expensive code when a lower level, less expensive code is warranted. Physicians must also accurately and thoroughly document that the e/m service was reasonable and necessary. section 1833(e) of the act prohibits payment for a claim that is missing necessary information. for e/m services, physicians must use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document the medical record with the appropriate clinical information. evaluation and management (e/m) services include office visits (new patient and established patient), hospital visits, and consultations. according to the CPT® Manual: the basic format of the levels of e/m services is the same for most categories. first, a unique code number is listed. second, the place and/or type of service is specified, 42 hbma billing • march.aPril.2013
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