Compliance in E&M Coding

E&M Codes

E&M coding (evaluation and management or intake codes in the hospital) is a wide ranging set of codes used to determine the service provided and therefore the reimbursement.  Major components include past family and social history, physical exam including a review of systems, and medical decision making.  The E&M codes range from 99201 to 99499.  The most common E&M CPT codes our clients encounter are:

*A complete list can be found at the end of this article.

Loose Compliance

Many (maybe even most?) providers do not worry about following strict guidelines when it comes to E&M coding.  Why?  E&M coding is unfortunately fairly complex, there is not a completely standard set of rules to apply, and it takes a lot of work to learn, train, implement, and maintain good E&M coding compliance.  It also is more time consuming on each patient encounter and doctors are already strapped for time and completely overloaded when it comes to paperwork associated with each patient visit, so it is no wonder this doesn’t get a lot of attention.

Short Cut

Many doctors take one component like complexity and use that to determine their CPT code for the encounter.  While many others use the amount of time they spent as a gage for what code to use (i.e. more time higher code, less time lower code).  Both can put the practice at risk.

Fraud vs Errors

In all of the years I have been in this industry, I have only once ever come across a physician or provider who was intentionally committing fraud, and it didn’t even involve E&M coding.  I don’t believe there are many providers who are trying to take advantage of the system.  But it often seems like there is not much reason to do the extra work required to be compliant on E&M coding.  This may be changing.

OIG scrutiny

There has been much greater scrutiny by Medicare’s watchdog (and prosecutor) the Office of Inspector General (OIG).  They have been looking increasingly at E&M coding and found that it is a significant issue.  An OIG report in 2014¹ found that “E/M services are 50 percent more likely to be paid for in error” and that this results in “billions of dollars in overpayments”.  This particular OIG report was looking at outpatient E&Ms, i.e. 99201-99215, which does not include hospitalist billing codes (CPT 99221, 99222, 99223 and 99231, 99232, 99233) or ER billing codes (CPTs 99281-99288) which means that the overall magnitude of the issue is even larger, which I’m sure the OIG is aware of.

Increased scrutiny from the OIG means increased audits (RAC).  Everyone should be on the lookout for these and make sure their medical billing is compliant.

Troublemakers

We were once asked to audit the ER billing practices of a large emergency physician group in California.  While we completed a comprehensive audit and for confidentiality will not share all of that, following is the chart showing the contrast between just two of the doctors in that group.  Notice anything concerning?

Note: Actual data from a coding compliance audit we performed on ER billing

Anytime a doc is coding 100% of their charts a particular way is a dead giveaway that there is a compliance issue.  And the fact that they were coding 100% of them at the highest level was real trouble.

The net is that even if you are compliant, someone else in your group may not be.  Maybe it is a mid-level NP you have working with you, or maybe it is the locum doctor you had in for a while, or maybe the new physician you have brought on to help with your growing practice.  These are all important to monitor.

New Trouble On the Horizon

Apache Health was recently quoted in an article in the Huffington Post with respect to ER billing and coding errors:

“We see the same issue not just in the ER, but in other areas of the hospital (and even in an office setting),” said Sean McSweeney, president of Apache Health, a medical billing company for clinics and hospitals. “These issues are often unintentional, but are simply the result of a doctor trying to quickly code and move on.”

The Huffington Post article author basically goes on to say that they found coding errors and then essentially did not have to pay for their hospitals bills.  This opens a completely new avenue of potential loss in the revenue cycle management process and the implications are far ranging.

Physician groups may need to be prepared for increased scrutiny from patients and insurers that the medical coding was in fact correct.  This means that periodic mini audits may occur and the practice should be prepared to audit each individual chart in case a patient requests this as part of an attempt to contest the bill.  If you can’t support the coding, you may be forced to abandon the claim and lose revenue.

Ensure Compliance

The lesson to be learned from all of this is that there is increased scrutiny on compliance in coding and increased ramifications to not being compliant.  If there are mistakes, you could be out financially (in the case of the article the hospital wrote off the entire bill) or from insurance companies clawing back reimbursement.

If it seems overwhelming, there are resources to help.  Reach out to your national association like ACEP, SHM, AAOS, and others, or to your medical billing company.  They should have ways to help you ensure compliance as a part of their business.

About Apache Health

Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company. The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup. Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients.  Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time. For more information contact:

Sean McSweeney

Apache Health

www.apachehealth.com

888-422-5514

Sources:

¹https://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf

Complete table of E&M CPT codes:

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