OIG Looking at Mis-Coding of E and M Claims

November 3, 2014
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OIG_Study_and_SurveyA recently released study from the Office of the Inspector General (OIG) of the US Department of Health and Human Services focused on improper Medicare payments for evaluation and management (E/M) services.

OIG_Study_and_SurveyA recently released study from the Office of the Inspector General (OIG) of the US Department of Health and Human Services focused on improper Medicare payments for evaluation and management (E/M) services. E/M services include visits to non-physician and physician practitioners that aim to manage and assess a patient’s health.  In 2010 Medicare paid $32.3 billion for all E/M services which made up almost 30% of all Part B payments for the year. 

The OIG completed this study in order to gather more information about E/M services, the billing of higher level codes, and the possibility of improper payments.  In 2012 the OIG released a previous report that indicated physicians had increased their billing of higher level codes for E/M services from 2001 to 2010.  This report also discovered that there was a higher likelihood of billing errors than in other services provided under Medicare Part B.  

In order to complete this study OIG conducted a national record review of random samples from Part B claims. These samples targeted E/M services from 2010 and included claims from “high coding” physicians and those from other physicians.  A “high coding” physician is one that routinely bills for higher level codes including E/M services.  The OIG utilized the expertise of certified professional coders to determine whether a claim was correctly coded, included a documented need for the higher level E/M service, and whether or not sufficient documentation accompanied the claim. 

The OIG discovered that Medicare paid $6.7 billion in 2010 for inappropriate E/M services.  These claims either lacked sufficient documentation or were incorrectly coded.  This $6.7 billion made up nearly 21% of all E/M Medicare payments for 2010.  Specifically, 19% lacked the required documentation and 42% were coded incorrectly.  Claims that included incorrect codes represented both upcoding for higher level claims and downcoding to lower levels than warranted.

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Based on this study the OIG developed a series of recommendations for the Centers for Medicare Services (CMS):

  1. CMS should educate physicians on appropriate coding and required documentation standards for all E/M services.
  2. CMS needs to continue encouraging contractors to review claims submitted for E/M services by high-coding physicians. 
  3. CMS should continue follow up on claims that were reimbursed in error for E/M services.

Understanding this OIG study and the subsequent report is essential for orthopedic surgeons in private practice. Your practice’s billing and coding procedures are vital to ensuring you receive the proper levels of reimbursement

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