Audit E/M coding--before the government does

When it comes to coding, the name of the game is accuracy. Code less than warranted and you lose out on reimbursement you can't afford to forgo. Code too high and risk scrutiny from the Office of Inspector General (OIG) and payers, also resulting in a potential loss of revenue.

Practices and authorities in recent years have been keeping a close eye on physicians' evaluation and management (E/M) coding in particular. For a variety of reasons--from coding tools in electronic health records; aging, more complex patients; widely available coding education; and, in some instances, fraud--physicians' use of higher-level E/M codes has soared during the past decade, Medscape Today reported.

In fact, according to a May report from the OIG, in 2001, office visits for established patients coded 99211, 99212 and 99213 accounted for 76 percent of the visits in this category, with 99214 or 99215 representing the remaining 24 percent. By 2010, the percentage of visits with the three lower codes dropped to 59 percent, while 99214 and 99215 visits rose to 41 percent.

Although the OIG is still investigating whether the surge in higher-level codes was appropriate, it has stated that "E/M services have been vulnerable to fraud and abuse."

Under the same theory, the government's recovery audit contractors (RAC) often focus on auditing E/M services, Physicians Practice noted. To ensure your practice comes up clean in a potential RAC audit, article authors Natalie Prazen and Karen Zupko recommend practices take the following steps:

  • Have the practice administrator or a consultant review coding and chart documentation for all physicians on a regular basis
  • Look closely at your top E/M codes for trends of under- or overcoding
  • Use online tools to compare your group's or a physician's coding against Medicare data for other physicians in your specialty or state
  • If you find your practice is exceeding the norms, take special care to ensure documentation and medical necessity support the higher-level codes, especially if the physicians use an electronic 'auto-coder'

To learn more:
- see the post from Physicians Practice
- read the article from Medscape Today
- see the OIG report