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.
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):
- Continue to educate physicians on proper billing for E/M services.
- Encourage Medicare contractors to review physicians’ billing for E/M services.
- 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.