Evaluation and management billing: Watch out for fraud, electronic medical records pitfalls

Increased payer scrutiny necessitates immediate changes to your coding practices


It’s time to revisit proper evaluation and management documentation. In fact, we are overdue in updating you on this topic. We’re concerned about current practices and, in this article, we will recommend immediate changes to your work , processes, and coding.

E&M documentation has been a major problem for many of us since the beginning of the documentation guidelines in 1995. All of you are painfully aware that a new set of guidelines was published in 1997 but was never officially adopted. Currently, one can choose to use either of the two sets of guidelines. In fact, Medicare auditors are required to use both and give you credit for the highest level achieved in either one.

The only major difference between the two guidelines is the documentation of the physical exam. The ’95 guidelines were not as detailed, and several areas were left to interpretation. We interpreted the ’95 guidelines in a very restricted manner for the first several years, and therefore taught the ’97 guidelines as the best way to document the physical exam. However, we learned after a few years that Medicare interprets the guidelines in a less comprehensive way, therefore making the documentation of the physical exam much easier and more reflective of the way urologists practice. Therefore, we have been strongly recommending, and teaching, the use of the ’95 guidelines since that time.

This point is worth repeating: We strongly recommend that you use the 1995 documentation guidelines for all of your E&M services.

Increased scrutiny by payers

There are several reasons to revisit your E&M documentation, starting with increased scrutiny by payers. A March 15 article outlined the new tools the government is using to fight fraud and protect the health care dollar (http://www.healthcare.gov/news/factsheets/fraud03152011a.html).

The article examines portions of the Affordable Care Act that are aimed at fighting “true” (deliberate) fraud. However, a number of the initiatives directly affect you, such as the $350 million to be spent over the next 10 years on increased scrutiny of claims, sophisticated data analytics, and additional law enforcement personnel charged with fighting fraud. In addition, the law sanctioned enhanced penalties, expansion of recovery audit contractor (RAC) activities, and greater oversight of private insurance abuses.

As you are well aware, more groups than ever are looking over your shoulder: Medicare carriers, RACs, the Office of the Inspector General, and Zone Program Integrity Contractors, to name a few. One example of this increased scrutiny comes from Medicare contractor TrailBlazer Health Enterprises, LLC, which recently released results of a chart review it conducted. (Of particular interest <span class=GramE>is</span> how the group identified the charts to be evaluated and its increased use of “medical necessity” in its determination of errors.) Through statistical analysis, TrailBlazer identified potential improper utilization of established patient visit services billed to Medicare.

Among TrailBlazer’s findings were that 91.32% of the charts reviewed from the J4 region (Colorado, Nebraska, Texas, and New Mexico) were reported incorrectly. In Virginia, only 51.43% were in error. Certainly, this is not a statistical example of error rates. However, it very vividly points out the accuracy of its software. It brings to mind the old saying, “You can run, but you can’t hide.”