Medicare Compliance & Reimbursement

Downcoding just two E/M visits a week can cost an arm and a leg. It may not seem like a big deal to bill a 99212 instead of a 99213 occasionally for evaluation and management visits. But those little reductions can add up. Let's say a three-physician practice downcodes from a level three to a level two office visit twice a week per physician. That's just six downcodings from 99213 to 99212 per week. Assuming a 48-week year, that adds up to $1,434 per year, according to consultant Mary LeGrand with Karen Zupko & Associates in Chicago.

"It is not insignificant dollars at all," says LeGrand. And that's just Medicare reimbursement numbers, not including other payors.

There can be a number of reasons why physicians feel compelled to reduce the level of their E/M codes, says LeGrand. One may be the fear of fraud and abuse scrutiny from the HHS Office of InspectorGeneral and the Program Safeguard Contractors. "Physicians believe that they are safer to undercode," says LeGrand, "so if they're not sure, or not comfortable with what level of code they report," they circle the lower code to be on the safe side. One major reason why many physicians downcode their E/M visits is because their medical decision making is not as strong as their history and physical exam. This could be simply because they have a patient with three chronic illnesses, requiring lots of history-taking and examination but little decision-making, notes Marcella Bucknam, HIM Coordinator at Clarkson College.

Whether MDM is the factor that drags down E/M levels depends on the physician's specialty, says LeGrand. In orthopedics, it's rare that MDM will be the factor limiting reimbursement, but it's likelier for ear, nose and throat physicians. Similarly, surgeons are likelier to be limited by history, "because they don't document as complete a history as a medicine physician," says LeGrand. "They do the work, they just don't document."

Sometimes a lack of education causes E/M downcod-ing, and sometimes it's just feeling overwhelmed with the increasing volume of casework, adds LeGrand.