Coding and overpayments are getting a lot of regulatory attention—are you in the government’s crosshairs? Evaluation and management (E/M) always tops the list of errors that are easy to make. Here’s how to avoid the most common E/M coding pitfalls.
HHS Targeting Overpayments
In fiscal year 2016, the Department of Health and Human Service’s Health Care Fraud and Abuse Control Program issued hundreds of millions of dollars in fines, captured hundreds of millions in restitution and seized tens of millions of dollars’ worth of assets. In all, the agency netted $3.3 billion for the federal government. The agency’s action has a high return on investment and even though funding was cut in 2016, the agency’s motivation to root out improper billing remains high.
In FY 2016 the agency reviewed nearly 50,000 claims and found an overpayment rate of 10.9 percent, with a projected overpayment of $40.5 billion, according to the Medicare Fee-for-Service 2016 Improper Payments Report. That error rate has been gradually trending upward from FY2008’s 3.6 percent. The error rate for E/M services was 0.8 percent, or $751,103,752—which garnered its own appendix in the report.
Determine Your E/M Level
E/M coding is among the most frequently billed physician services, says coding expert Elin Baklid-Kunz in a conference for Audio Educator, “How to Avoid Common E/M Coding Errors.” Auditors, enforcers and whistleblowers are continuing to look hard at E/M billing for improper claims.
The key to correct E/M coding is to code services at the proper level. Baklid-Kunz offers six steps to determine your E/M level:
- Determine the category and subcategory of service
- Determine medical necessity—the nature of the presented problem
- Determine the level of history obtained (HPI, ROS, PFSH)
- Determine the level of examination performed
- Determine the complexity of medical decision making—the number of diagnosis or management options, the risk of significant complications, morbidity, and/or mortality, and the amount and/or complexity of the data to be reviewed
- Determine the final E/M level—determine whether time is a dominant factor
Avoid Common E/M Piftalls
By changing just a few of your day-to-day processes, you can avoid these common E/M pitfalls:
- Noting that all new patients are consults
- Mislabeling preventive actions as problem actions
- Cluster coding or presumptive coding
- Mislabeling an inpatient in for observation as outpatient
For presumptive coding, it is important to note that suspicious or flagged activity by one physician can get an entire practice audited. Using just one level of an E/M service in a category increases the risk of audit.
And when it comes to medical necessity, a common issue is over-documentation of E/M services when the presenting problems, patient acuity or decision-making complexity actually supports a lower-level code. The solution? Your documentation must support your reported level of service. Because CMS’s standard is that you can’t bill a higher level of E/M service when a lower level is warranted, you can’t just focus on the volume of documentation to support your E/M level.
Get a Hand from a Pro
Stay tuned as Baklid-Kunz updates E/M codes for 2018. Her conferences are perfect for coding pros, billing specialists, practice managers, HIM directors, compliance officers, case managers and physicians. Sessions cover how to correctly choose correct codes and avoid under-documentation, common errors and pitfalls in E/M, documentation requirements, which set of E/M guidelines to use, and the OIG Work Plan and E/M services.
