Two Physicians Reviewing Chart

More medical practices may have their records audited after a report by the Office of Inspector General showed an increase in the use of higher-level evaluation and management codes.

Government Scrutinizing Medical E/M Coding Practices

  • 8/3/2012

Government Scrutinizing Medical E/M Coding Practices

A report by the Office of Inspector General (OIG) on improper evaluation and management (E/M) coding of medical services could increase audits on medical practice records. The study outlines E/M coding trends between 2001 and 2010, including the growing number of practices billing for higher-level E/M codes and as a result, receiving larger payments for their services.

“Now that the OIG has found this trend, it has recommended that the Centers for Medicare and Medicaid Services (CMS) focus on examining records to catch medical practices that billed for E/M services beyond what was necessary. You must back up your billing decisions with comprehensive documentation,” explains Karla VonEschen, a health care consultant with CliftonLarsonAllen.

E/M billing trends

The report highlights some interesting trends and changes in E/M billing between 2001 and 2010:

  • Medicare payments for E/M services increased by 48 percent.
  • Payments for E/M services increased from $22.7 billion to $33.5 billion.
  • Billing for codes 99214 and 99215 increased by 17 percent.
  • Physicians who consistently billed higher-level E/M codes are widespread; they practice in 47 of the 50 states.
  • Of the specialties reviewed in the study, internal medicine, family practice, and emergency medicine consistently billed higher-level E/M codes more than other specialties.

How to code properly

According to VonEschen, physicians must use three key components to determine the appropriate E/M code level: patient history, physical examination, and medical decision making. Not every element must be documented for every patient. The extent of information gathered should be based on the provider’s clinical judgment and the presenting problem.

Patient history

The patient history should chronicle the symptoms or problems being addressed during the encounter, and include:

  • A concise chief complaint
  • History of present illness (HPI)
  • Review of symptoms (ROS)
  • Past medical, social, and family history, when appropriate

A patient’s medical record should be a chronological report of the treatment they have received. This information is not only necessary for the appropriate claims payment, but it’s important for the patient’s ongoing care.

Physical examination

Examinations are broken into four levels: problem focused, expanded problem focused, detailed, and comprehensive.

The examination may include a single or several organ systems, depending on clinical judgment, patient history, and the nature of the presenting problem. It’s often assumed that documentation in this area is written in the progress notes, but this is not always the case. It’s important to remember without thorough documentation, there is no actual evidence of an exam during the patient encounter.

Medical decision making

Medical decision making (MDM) refers to the complexity of establishing a diagnosis and/or selecting a management option. It is composed of the presenting problem, amount and/or complexity of data reviewed, and the risk the illness presents to the patient.

VonEschen outlines an example of proper documentation:

Patient presents to the office today with a history of nose bleeding. This is the third occurrence I have treated her for. The bleeding has been occurring off and on for approximately 10 days. She states the bleeding has stopped, but she now states she’s had a mild headache. Patient denies taking any aspirin. Patient also denies any chest pain or shortness of breath. Normal tympanic membranes. The examination of the nares shows evidence of past bleeding site; it’s now resolved. Neck is supple and lungs are clear. Oropharynx is normal.

Assessment and plan: Recurrent nosebleeds. The patient should return if bleeding reoccurs.

This example includes the chief complaint (indicated by nosebleed), quality (resolved), duration (past 10 days), and modifying factor (mild headache). The review of systems consisted of the cardiovascular and respiratory system. There was no past, family, and/or social history noted. The HPI states the patient has been treated for nose bleeds at a prior visit, and had the neck, lungs, ears, nose, and throat examined. For MDM, there is one self-limiting or minor problem (recurrent nosebleed), no diagnostic procedures ordered or reviewed, and the risk is minimal.

Preventing an audit

The best way to remain compliant with E/M coding rules is to maintain thorough medical records. “There is an old saying when it comes to medical documentation, if it’s not documented, it’s not done,” says VonEschen.

She recommends some steps you can take to ensure your medical records contain appropriate documentation:

  • Make your medical record documentation clear and concise to support the E/M level billed for payment. This is required for appropriate billing and accurate payment of E/M codes.
  • Read the CMS evaluation and management guidelines, which are also in the front chapter of current procedural terminology (CPT) coding manuals.
  • Review your charts periodically to see if you are appropriately documenting and billing for services. Examining your chart documents now can help you find areas that need improvement before you encounter any government inquiries.

How we can help

We can answer your E/M coding or guideline questions, and we offer the following services:

  • A chart review that focuses on E/M codes. The OIG recommends having an outside vendor conduct a review, even if you have an internal review process in place.
  • Educational training for professional coders and physicians. This is an opportunity for you to ask questions and receive guidance on appropriate coding, denials, documentation improvement, and guidelines.
  • Recommendations for documentation improvement to support billed services.
  • Research of complex issues.

Karla VonEschen, CPC, Health Care Consultant or 612-376-4603