OIG to Send List Of Docs Who Overbilled High-Level E/M Codes

Thu, May 31, 2012 --


Take time to examine your practice’s E/M trend line and see if your frequency of reporting high-level E/M codes has increased dramatically over the years. If that has happened, be ready to find the reasons why, before your MAC begins forcing you to make that determination.

A recent OIG study revealed that physicians increased their billing of higher-level E/M codes across all categories (inpatient, outpatient, etc.) between 2001 and 2010. In fact, the OIG sent CMS a list of 1,700 physicians who were identified as “consistently billing higher-level E/M codes in 2010.”

The report results were summarized as follows by the OIG in its report, “Coding Trends of Medicare Evaluation and Management Services,” which was published on May 9.

Outpatient: For outpatient services, the report noted that a shift was seen “in billing from the three lower-level E/M codes to the two higher-level codes. Combined, physicians increased their billing of the two highest-level E/M codes (99214 and 99215) by 17 percent” over the study period.

Inpatient: When it came to hospital visits, the OIG noted that billing the lowest code (99231) decreased 16 percent, whereas billing 99232 code increased six percent and 99233 increased by nine percent.

Emergency: The shift was even more pronounced among emergency department visits, the report stated. During the study period, physicians decreased how often they billed the four lowest codes (99281-99284), but increased billing the highest code (99285) by a startling 21 percent.

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High-Level Codes Don’t Necessarily Equal Fraud

Many reasons exist that could cause a practice to legitimately begin coding more high-level E/M services than in the past. For instance, the practice may have begun seeing a more complex patient population who have more chronic problems that require intense management. Or the practice may have been audited and discovered the physicians were downcoding claims, so now the physicians are correctly coding based on the documentation, which warrants more 99214s and 99215s.

If you fit into one of the legitimate billing categories such as these, you shouldn’t fret the new OIG study. If, however, you aren’t sure how your physicians arrive at their E/M codes, it’s time to offer a quick education session at your practice.

The OIG recommends coding education as the number-one priority following the results of this report, and also encouraged MACs to review physicians’ E/M billing patterns to avoid improper payments. “CMS should conduct additional reviews of physicians who consistently bill higher level E/M codes to ensure that their claims are appropriate,” the OIG recommends.

To read the complete report, visit http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf.


Barnali is a medical coding and billing writer at TCI who has worked in the healthcare industry since 2009. She holds a master’s degree in English literature and a diploma in advertising and marketing. She enjoys writing about ICD-10 and Medicare compliance.

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