Upward Trending of E/M Levels Worries OIG

The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) says that physicians are reporting high-level evaluation and management (E/M) codes more frequently for all types of E/M services. Medicare payments for E/M services increased 48 percent in the decade ending 2010, from $22.7 billion to $33.5 billion. Overall, Medicare payments for Part B goods and services increased 43 percent during the same period, from $77 billion to $110 billion.

Using the Part B Analytics Reporting System, the OIG analyzed E/M services to determine coding trends from 2001-2010. The resulting report, “Coding Trends of Medicare Evaluation and Management Services,” identified (but does not name) 1,700 physicians “who consistently billed higher-level E/M codes,” despite treating similar patients to other physicians in the review. These “outlier” physicians billed the two highest codes within a visit type at least 95 percent of the time and are, the OIG implies, ripe for audit.

Evaluation and Management – CEMC

Significantly, the OIG “did not determine whether the services billed by physicians who consistently billed higher level E/M codes were inappropriate or fraudulent.” The language in the report makes it clear, however, that the OIG feels the upward trending of E/M services is due, at least in part, to abusive or fraudulent activity. In response, OIG proposed three recommendations to the Centers for Medicare & Medicaid Services (CMS):

  1. Continue to educate physicians on proper billing for E/M services.
  2. Encourage Medicare contractors to review physicians’ billing for E/M services.
  3. Review physicians who bill higher-level E/M codes for appropriate action.

CMS concurred with the first two recommendations, and “partially concurred” with the third recommendation. The OIG has already shared with CMS its list of the approximately 1,700 physicians it identified as “consistently billing higher level E/M codes in 2010,” and “will also consider these physicians for further review in our continuing series of evaluations of E/M services.”

As indicated by its statement above, the OIG will continue to investigate billing for E/M services, and plans to issue two additional reports. The first of these will determine the appropriateness of Medicare payments for E/M services. The other will assess the extent of documentation vulnerabilities in E/M services using electronic health record (EHR) systems.

The bottom line: Providers can expect greater scrutiny of E/M services in the months and years ahead.

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13 Responses to “Upward Trending of E/M Levels Worries OIG”

  1. Kitchi says:

    This is just irritating to me. Physicians are damned if they do and damned if they don’t.

    I want to see the research showing what a physician billed prior to the implementation of an EMR/EHR system. Then I want to see the research in the E/M billing with an EMR leveling the service. Compare the two. You will find that an EMR will frequently bill a higher level of service for an established patient based on the amount of documentation and not the MDM or medical necessity. That’s a big part of why MCR has seen a rise in E/M services.

    The problem is that if the physicians don’t “get on board” with the whole EMR, it will hurt financially. Even though, MCR has not made it MANDATORY, they are going to cut your money if you don’t. So when you do get an EMR, you will be identified as billing higher E/Ms and audited?!?!?

    Com’on folks! I realized some physicians take advantage and work the system but the ones that don’t outweigh the ones that do. When I audited my physicians, many of them undercoded, especially established patients. They have been undercoding for years, now they have something to help them level an E/M service and they are still afraid to send out a level 4.

  2. MSW says:

    I think that CMS may fail to realize that the transition to electronic medical records will remind physicians to include in their documentation those examinations or questions that they may not have been routinely asking. As the documentation improves, the level of services may, indeed, increase. As long as the new level of services can be proven to be medically necessary, the rise in reimbursement is to be expected. Additionally, the EMR, while helpful as a reminder, can also allow more in-depth documentation than physicians previously might have provided. The associated increased reimbursement costs will be one of the extra implementation costs of ICD-10 because the increasingly detailed documentation will be necessary. As physicians change their documentation styles in preparation for the implementation of ICD-10, the reimbusement costs of services provided may be expected to rise prior to full ICD-10 implementation. In other words, you pay for what you require in some fashion!

  3. KAT says:

    EMR is the key factor to the increase. The “ease” in documentation available with templates and the copy/paste option, to name a couple. The ability to create a higher level note is done by the click of the mouse. It would not be a surprise if the E&M Documentation Guidelines change due to the many issues that arise from the onset of EMR. Perhaps further specification/stress on problem pertinent documentation.

  4. katididit says:

    Agree with the EMR statement. At my work [insurance] we can pull out what is ‘templated’ and look at what is pertinent to that days visit. So for example if there is the same ‘templated’ history present on each visit being reviewed, it doesn’t count if it is not pertinent to CC for the visit. We consider that extra non-related information ‘fluff’. As in it only appears there because of the template and as if they are trying to ‘fluff’ or inflate the visit.

  5. #codersstillwanted says:

    I agree. Also…more and more physicians and hospitals are relying on properly trained and experienced coders/auditors to assist them with understanding proper documenation and how it relates to medical necessity, while not only relying on EMR to assign a code. As a physician coder I educate my physicians on on how to watch and avoid the underlying disease “FSS”, fluff & stuff syndrome and have come to realize that many of them do not have the time to “purposely” copy & paste for higher reimbursement as opposed to rushing through a note to get it completed. This article confirms the continued need for trained coding staff as opposed to only relying on EMR.

  6. Purelycoder says:

    Does anyone know where I can find Benchmarks for E&M codes for 2011 or even 2010? I’ve looked all over the CMS website and can’t find this information.

  7. Jeremy Reimer says:

    I sat through an EMR presentation last month and was shocked. The ROS portion has boxes for each system that can be checked as the doctor/examiner goes over them. There is also one box on top of all the others that can be checked, and it highlights all the systems below.

    When I brought this to the presenters attention, that this feature not only enables upcoding, it promotes it, she of the typical eye candy pharm/med rep replied back, “Well, how is that any different from a paper office note? The doctor just checks all the systems anyway, and records the abnormal findings.”

    If her doctors are doing that, they shouldn’t be. Also, the EMR imports the patient’s history from previous visits with a similar check box. I explained that the extent of the history was a factor in determining E/M level, and this too would lead to upcoding. Again, I was met with the same, “So how is this different than what a doctor already does?”

    I explained that the doctor would write “no change” or leave that portion of his notes empty if he didn’t take a full history. The EMR would look like the doctor took a complete medical/social history, and in lies the difference. The EMR does not contain a “no change” feature.

    At one point, I attempted to ask another, more innocent question which was met with a “you’ve already reached your limit” response. We all know there is truth in joking, and I could see that my previous questions had made the former pageant princess uncomfortable.

    The point of all of this is to show that EMR are great for reducing manual data entry, but will also enable if not promote upcoding.

    And for the 1,700 doctors mentioned above that currently code 95% of their patients as level 4 and 5 visits- Shame on you! You’re the rotten apples that give everyone a bad name. If Medicare and other carries want to save money, cutting payments isn’t the answer. Auditing (and prosecuting) doctors like that is the way to do it….

  8. KMG says:

    I want to see the research showing what a physician billed prior to the implementation of an EMR/EHR system. Then I want to see the research in the E/M billing with an EMR leveling the service. Compare the two. You will find that an EMR will frequently bill a higher level of service for an established patient based on the amount of documentation and not the MDM or medical necessity. That’s a big part of why MCR has seen a rise in E/M services.

    The problem is that if the physicians don’t “get on board” with the whole EMR, it will hurt financially. Even though, MCR has not made it MANDATORY, they are going to cut your money if you don’t. So when you do get an EMR, you will be identified as billing higher E/Ms and audited?!?!?

    Com’on folks! I realize some physicians take advantage and work the system but the ones that don’t outweigh the ones that do. When I audited my physicians, many of them undercoded, especially established patients. They have been undercoding for years, now they have something to help them level an E/M service and they are still afraid to send out a level 4.

    (apologies if this gets posted twice)

  9. kcode says:

    Isn’t it ironic that the purpose of the electronic records was to reduce errors and cost?

  10. jkfandel says:

    No mention of removal of consult codes which are now being reported as E/M. Would think this has something to do with the bump.

  11. Njohnson says:

    I agree with JReimer.” we have been using EHRs for two years and they may not do it to purposely upcode but for convenience and speed.

  12. cchcpc says:

    You’re right about the consult codes! Does anyone remember how the OIG was going to watch provider’s E&M billing to see if you billed too many of one code? Warning: billing 99213 most of the time might get looked at more than someone spred out all over. I’ve also have had an increase in Medicare patients: baby boomers and SSA disability patients. You also can go to the Medicare Website (not CMS) and find all kinds of promotions for people to see their Doctors and use their benefits.?? I do not have EMR yet but have seen the warning of “Templating”. I pulled documentation/progess note forms off UnitedHealthcare’s site, they cover lots of ROS boxes, etc just like EMR. I do resent to implication that #’s MUST be F&A, they’ve been singing the documentation song a long time-at least the last decade?

  13. TammyDi says:

    I agree with jkfandel. Not being able to utilize consult codes definitely contributes to the rise of levels.

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