Self-Audit Your E/M Coding to Avoid Overpayments

55 percent of EM Claims Incorrectly Coded, Improper Payments for Evaluation and Management, Significant Medicare coding errors, Coding Consultation EM Services Correctly, Evaluate Your EM Coding

Don’t let the payer find your E/M errors before you do — perform self-audits of your E/M codes at least annually! That’s the lesson providers should take away from a recent report from the Medicare administrative contractor (MAC) NGS Medicare.

NGS Reports Error Rate of More Than 70 Percent

NGS reported that in an audit of claims submitted in October, November, and December 2015 with E/M services using CPT® codes 99223 and 99233, error rates ran in a range that topped 70 percent. Most claims for these services were reduced or denied because the records lacked documentation supporting this level of services. As you know, 99223 requires three key components: a comprehensive history, a comprehensive examination, and medical decision making of high complexity. Code 99233 requires at least two of these three components: a detailed history, a detailed examination, and/or medical decision making of high complexity. In the case of 99233, the patient is usually unstable or has developed a significant complication or new problem, requiring the provider to spend about 35 minutes at the bedside and on the patient’s hospital floor or unit.

Ensure Proper Reimbursement— Perform DIY Audits Annually

In 2014, officials at the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) reported that in 2010, 55% of all E/M claims were incorrectly coded to the tune of $6.7 billion in inappropriate payments. Since then, payers have looked closely at all E/M claims. But performing self-audits to evaluate your E/M coding at least annually can help you identify coding and documentation problems before they catch outside auditors’ eyes.

Learn How to Get Started With Self Audits

A self-auditing program for E/M codes will require reviewing and vetting large amounts of documentation. The encounter notes on your E/M codes must illustrate all the required elements for the E/M level you billed for. For that reason, when you do your review of E/M charts, make sure the documentation for history, exam, and medical decision-making truly support the level of E/M you’re claiming. Fortunately, you can follow either the 1995 or the 1997 E/M documentation guidelines. You can even switch back and forth between guidelines by encounter — you don’t have to stay with just one guideline for all claims.

Don’t Go On Autopilot With E/M Coding

Watch out for “automatic” E/M coding. In these cases, you’ll see a pattern where coding doesn’t line up with documentation. Usually this happens when your practice codes at a specific level for patients with certain issues, such as a practice of incorrectly reporting 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) for every established patient who comes in for treatment of a sinus infection. Instead, coders should report E/Ms based on the specifics of the individual encounter.

Do You Self Audit?

The practice of self-auditing codes sounds like a lot of work, especially when coders have so much already on their plates. However, the benefit to this proactive practice seems to outweigh the effort required. Has that been your experience? Let us know in the comment box below. We love to hear from you!

SuperCoder’s EM Auditor Improves Compliance and Productivity!

Want to improve your productivity and accuracy while making sure your coding complies with E/M guidelines? Automate your E/M coding chores with SuperCoder’s EM Auditor, using quick screen navigation to assign levels to the key components or time for coding or auditing. With logic from 14 different audit tools, including Marshfield Clinic’s point system, EM Auditor will help you increase your productivity, eliminate overpayments, improve your documentation, and ensure compliance for high-level codes. Check it out!


Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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