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Monday, July 30, 2012

The Office of Inspector General looks at evaluation and management services

The services that family physicians report most often are evaluation and management (E/M) services. The codes for these services represent the "bread and butter" of family medicine. Thus, it's a big deal and understandably unnerving when the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services decides to scrutinize them.

However, that's just what the OIG did, and the resulting report, Coding Trends of Medicare Evaluation and Management Services, found that, from 2001 to 2010, physicians increased their billing of higher level E/M codes in all types of E/M services. This finding, of course, comes as no surprise to those in the industry, and there are many plausible and justifiable explanations for it, including the following:

  • Extensive coding education provided to physicians during that time, leading to arguably better coding of what physicians have always been doing,
  • Implementation of electronic medical records, which facilitate documentation,
  • Greater incidence of chronic diseases.

It's notable that the OIG did not evaluate the appropriateness of Medicare E/M payments or the documentation behind the claims in question. The OIG indicated that it would save these questions for subsequent evaluations. The OIG did recommend that the Centers for Medicare and Medicaid Services (CMS) encourage its contractors to review physicians’ billing for E/M services. CMS partially concurred with the OIG recommendation. However, they noted that the average E/M error was approximately $43, while it cost between $30 and $55 to review an E/M note. Thus, CMS pointed out that there were other Part B areas that might have a higher priority for it and its contractors.

So, what's a family physician to do? First, don't panic. As the CMS response implies, they have bigger fish to fry when it comes to claims reviews. Second, do make sure that your documentation supports the level of E/M services that you are billing. With the OIG paying attention, CMS may follow suit, and you need to be prepared, if they do.

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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