Are your coding practices inviting the OIG into your office? - DoctorsManagement Are your coding practices inviting the OIG into your office? - DoctorsManagement

Are your coding practices inviting the OIG into your office?

Recently the Office of Inspector General (OIG) released their long-anticipated first report regarding Medicare Evaluation and Management Service coding trends. Ultimately, they came up with three recommendations to the Center for Medicare and Medicaid Services (CMS). CMS accepted the first two recommendations and put the third under consideration.

The first two OIG recommendations that CMS accepted were to
continue to educate physicians on proper billing for E/M services;
encourage CMS contractors to review physicians’ billing for E/M services.

The third recommendation was to review the 1700 physicians that were identified in the study who billed at a higher level E/M code to ensure that their claims are appropriate. (Now, that is what we call a truly targeted audit!)

Begin by comparing your E/M utilization with that published by CMS. This data demonstrates E/M utilization by specialty. Providers that demonstrate significant overutilization (and even underutilization) of any given code are considered “outliers” and are exposed to audit. (Click here to get the Medicare utilization statistics for part B)
The E/M code level should always be selected using medical appropriateness/necessity based on the problem(s) addressed. Be sure to document elements of the history and exam toward the level of service as opposed to choosing the level based solely on the volume of documentation.
Consult with a professional coding consultant or coding auditor for education and assistance.

What is most concerning about the OIG’s initial findings is that it is consistent with what we are seeing with clients for whom we are conducting coding audits. They are falling into a “trap” with EM coding, which is not hard to do. And, the longer you allow it to continue, the harder it is to break the habits of your providers and get their coding in line with what their documentation supports.

While most consultants/auditors want to talk about over-coding, our team focuses on under-documentation. When you look at the presenting problems (i.e. Chief Complaint) the patients often have conditions that, on the surface, would warrant a higher level of service. Due to poor documentation or cloning of the medical records, however, their coding gets down-coded and results in a loss of revenue. THIS CAN BE PREVENTED!

The OIG report that was released May 2012, indicates that Medicare has seen a 48% increase in payments for E/M services – this ties directly to spending that jumped from $22.7 billion in 2001 to $33.5 billion in 2010. The study was conducted by the OIG using their Part B Analytics Reporting System, which looked for E/M service trends over the years 2001 to 2010. The OIG stated that they “analyzed physicians’ E/M claims to identify physicians who consistently billed higher level (i.e., more complex and more expensive) E/M codes in 2010.” The interesting part about their study, however, is that they did not assess if the levels billed were appropriate based on documentation and presenting problem.

The report focused on three major E/M services identified in the final report: established patient office visits, subsequent inpatient hospital care, and emergency department visits. The bulk of payments made by Medicare were for established patient encounters. This will become a major area of focus moving forward and believe me, with this report now public, it will not be long before other payors are ramping up their efforts to audit your E/M services more aggressively. You can expect more letters from your carrier indicating they have conducted a “Probe” audit of your claims and identified aberrancy in your 99214 and 99215 claims. I know the normal reaction is for providers to simply begin the process of down-coding their claims to stay off the radar screen but doing that results in unnecessary losses in revenues.

According to the report, “while the middle code (99213) was billed most often during the 10-year period of their review, there was a shift in billing from the three lower level E/M codes to the two higher level codes. I attribute this personally to the addition of EMR/HER systems to the mix. Many of the early systems, and even still a few around today, prompt physicians to select additional elements of the HX or EX to gain a higher level of service, or even worse, the physicians carry forward work performed at previous encounters that is irrelevant to the current encounter to try and up their level of E/M service; this is referred to as “Cloning.” The big gotcha is that physicians increased their billing of the two highest level E/M codes (99214 and 99215) by 17% from 2001 to 2010.”

Subsequent inpatient hospital care visits were the second highest cost for E/M service by Medicare in 2010. “In 10 years, physicians’ billing shifted from lower level to higher level codes.” The report goes on to discuss “the billing of the lowest level code (99231) decreased 16 %, while the billing of the two higher level codes (99232 and 99233) increased 6% and 9%, respectively.” “Clustering” is another major concern of the carriers.

If you have questions about this topic or any other issues around the business of medicine, contact us via email or call us at 800-635-4040.