Physician evaluation and management codes draw audit scrutiny

Feb. 28, 2018

Improperly coded claims, whether overpaid or underpaid, can cause a strain on a medical office’s reimbursement in terms of denials and lost revenue. Practice Management Institute introduced a new certification program to help provider offices establish an ongoing internal auditing program that monitors proper documentation and correct evaluation and management guidelines.

Libby Purser, a health information management supervisor for a north Texas multi-specialty provider network said that a clean claim should be paid in about 15 days, but if it’s denied it could take anywhere from 30 to 120 days. That in itself is incentive to have proper training for staff.

Medical coders need auditing skills, especially when it comes to reviewing evaluation and management reporting. Medicare inappropriately paid $6.7 billion for claims for E/M services in 2010 that were incorrectly coded and/or lacking documentation, representing 21% of Medicare payments for E/M services that year, according to a 2014 report conducted by the Departments of Justice, and Health and Human Services. The study indicated that E/M services were 50% more likely to be paid for in error than other Part B services and most of the improper payments resulted from errors in coding and from insufficient documentation. (1)

Employing certified professionals helps protect healthcare organizations and avoid potential problems. Laying the groundwork means provider and reimbursement staff training from organizations like PMI to reduce the risk of improper payments and audits.

Regardless of the type, all medical claims must account for certain factors. These include documentation of each patient encounter with relevant, accurate information, identification of health risk factors, and the patient’s response to treatment, among other general principles.(2) However, many healthcare organizations rely on electronic health record (EHR) systems, which make it easy for providers to use features like auto-fill and copy/paste. If these types of features aren’t monitored carefully, incorrect payment is possible as a result of inaccurate charting.(3)

PMI’s new Certified Medical Chart Audit–E/M will be taught in select markets and online beginning this spring. PMI also offers coding and auditing classes and certifications that address E/M coding and auditing.

Sources:

  1. The annual report of the Department of Health and Human Services and Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2014 https://oig.hhs.gov/publications/docs/hcfac/FY2014-hcfac.pdf
  2. Evaluation and Management Services. Centers for Medicare & Medicaid Services.
  3. Over coding? Under coding? RIGHT coding! Novitas Solutions.

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