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It’s Time to Re-evaluate Your E/M Coding

By Suzan Berman, CPC, CEMC, CEDC
With implementation of the electronic health record (EHR), it’s more important than ever to ensure documentation supports the individual level of service for each patient. Templates, smart phrases, easy text, and other shortcuts allow clinicians to document effortlessly without taking medical necessity into account. This is troubling to payers, and should be to the companies creating the records (as well as the providers using them).
OIG Does the Math: E/M Levels Rising
In May 2012, the Office of Inspector General (OIG) published “Coding Trends of Medicare Evaluation and Management Services,” illustrating a marked shift over time toward billing for higher-level evaluation and management (E/M) services. The OIG doesn’t directly blame EHR use for the trend in the report; however, it’s clear that the OIG is keenly aware of how EHRs can affect E/M billing.
Details of the report show that between 2001 and 2010, Medicare increased the payment of E/M services from $22.7 billion to $33.5 billion. Dates of services toward the end of the survey period include a larger sample of electronically documented records.
The OIG concluded in the top three categories reviewed (subsequent hospital visits, established patient visits, and emergency room services), the “middle” code (e.g., level 3 for the established and emergency services) was the most often billed service; however, higher levels of service are being billed more frequently. A statistical comparison is made in Table A for established patient visits.
Table A

Code 2001 2005 2010
99211 6% 5% 4%
99212 16% 12% 9%
99213 54% 52% 46%
99214 21% 28% 36%
99215 3% 3% 5%

Source: OIG analysis of 2001 and 2010 Part B Analytic Reports (PBAR) National Procedure Summary File (http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf), appendix C, page 21.
With regard to subsequent hospital services, 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components; An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity (mid-level code) is submitted most often. As you can see in Table B, however, there is a shift between 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components; A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity and 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components; A detailed interval history; A detailed examination ; Medical decision making of high complexity from 2001-2010.
Table B

Code 2001 2005 2010
99231 31% 22% 15%
99232 53% 58% 59%
99233 16% 20% 25%

As shown in Table C on the next page, emergency service codes saw the biggest change between levels of service.
Table C

Code 2001 2005 2010
99281 2% 1% 0%
99282 9% 5% 3%
99283 31% 27% 20%
99284 32% 30% 29%
99285 27% 38% 48%

Specialties billing higher services more often were family practice, emergency medicine, and internal medicine, with obstetrics/gynecology (OB/GYN), showing the largest percentage increase (4.3 percent, versus 1.9 percent overall) of physicians who billed only higher-level services. Geographic location was not a factor in the results. Only three states didn’t have physicians who consistently billed higher service levels in 2010: Montana, Nebraska, and Wyoming.
Physicians who bill higher levels of service might argue that they are seeing older patients, sicker patients, or patients with co-morbid conditions. OIG results didn’t support this theory. Patient populations were approximately the same age across the study, with the same diagnosis codes submitted, and the patients of those physicians consistently billing high-level services were, in aggregate, no sicker than average.
CMS Is Gunning for E/M Upcoders
As a result of this report, the OIG recommended the Centers for Medicare & Medicaid Services (CMS) continue to educate the physician community on the appropriate application of documentation guidelines. This could include letters, in-person seminars, teleconferences, etc. Medicare carriers also will be reviewing a greater number of E/M services.
The OIG has already provided CMS contractors with the names of physicians who it found to be consistently billing higher levels of services and, depending on a cost/benefit analysis, there will be more extensive reviews done for those physicians.
EHRs are an amazing tool in the health care environment. When designed and used properly, they help to improve office flow, patient care, and the revenue stream. The higher levels of service the OIG found in its recent study might have been billed appropriately (The OIG says in the report that it “did not determine whether the services billed by physicians who consistently billed higher level E/M codes were inappropriate or fraudulent.”), but without proper documentation in the medical record, there’s nothing to substantiate both the level of service and medical necessity.
Get Moving, Start Educating
The provider community could view this report as a call to order. Documentation is becoming more robust and more transparent amongst agencies and other providers. It must be clear, clean, and relevant. The provider community must put in place appropriate documentation improvement plans—and not just in preparation for ICD-10-CM, but for cleaner claims, more appropriate billing, and clearer care plans that ultimately result in better outcomes for patients.
Clinician education should be continual and timely. Physicians should welcome the education and not feel overwhelmed, over-scrutinized, or threatened. Educators should be accommodating as to where and when education is done, and must understand the providers’ prospective. Training tools should be developed to deliver information in a variety of ways. Meeting in small spans of times (taking a short break from patients or meeting early in the morning, for instance) might be appropriate alternatives to lengthy sessions. Weekend seminars and evening meetings with colleagues might also be great settings to provide billing and coding education. Webinars and teleconferences are also very productive ways to convey this information. The more the guidelines are reviewed, the easier they are to adapt into the patient visit workflow.
Suzan Berman, CPC, CEMC, CEDC, is the senior director of Physician Services for Health Revenue Assurance Associates. She serves on the OptumInsight Advisory Board and as Coding Institute Editorial Advisory Board member. She is a former AAPC National Advisory Board (NAB) and AAPC Chapter Association (AAPCCA) Board of Directors member. She speaks nationally for organizations such as the University of Pittsburgh, The Coding Institute, Advanced Career Solutions, AAPC, MGMA, and OptumInsight.

Evaluation and Management – CEMC

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