Lessons from OIG Audits of Physician E/M Services (Part 1)

Welcome to part one of this three part series where I’ll cover six important lessons we can all learn from the OIG’s audits of physician E/M services. These six lessons can help you ensure that your claims are sufficiently documented.

Background

Medicare paid $32.3 billion for Evaluation and Management (E/M) services in Fiscal Year (FY) 2010 which represents almost 30% of Medicare Part B payments for that year. E/M services fall into various broad categories which reflect:

1. Type of Service
2. Place of Service
3. Patient Status

These categories are referred to as “visit types.” They are further separated into three to five levels that mirror the complexity of a visit and match the Current Procedural Terminology (CPT) codes for coding and billing purposes. The higher level codes within a visit type also correspond to increased complexity of E/M Services and higher reimbursement rates.

The OIG reviewed physician billing patterns for E/M services for a period of nine (9) years from 2001 through 2010 and found that physicians increased their coding and billing of higher level codes for E/M services in all visit types. The OIG provided no insight as to the possible reasons for such increases in higher coding and billing. I suggest these possibilities:

1. Lack of education and certified professional coding (CPC) certification of staff
2. Lack of ongoing professional development of coding and billing staff
3. Stagnant government reimbursement increases within the Medicare Physician Fee Schedule (MPFS) warranted focused coding and billing approaches for providers

Lesson #1 – Comprehensive Error Rate Testing (CERT) Program

The Centers for Medicare and Medicaid Services (CMS) reviews the appropriateness of claims for E/M services through the CERT program. The OIG utilized data from the program for analysis of errors related to E/M services.

For example, in review of the 2011 CERT report, CMS found that E/M services made up a large proportion of Part B improper payments and were 50% more likely to be paid in error than other Part B services. The majority of these improper payments for E/M services were due to:

• Incorrect coding
• Insufficient documentation

Lesson #2 – Documentation of E/M Services

The OIG references multiple guidelines from CMS regarding documentation of E/M services that correspond to errors found in audit data from reviewed reports. Here are a sample of items referred to:

• Documentation must support medical necessity and appropriateness as well as the E/M service - Medicare Program Integrity Manual, Pub. 100-08, ch. 3, § 3.3.2.1. See also Social Security Act § 1156(a)
• Clear and concise medical record documentation is required in order for physicians to receive accurate and timely payment for furnished services - CMS, Evaluation and Management Services Guide, December 2010, p. 3
• In the medical record, physicians should document the care a patient received and pertinent facts, findings, and observations about the patient’s health history - CMS, Evaluation and Management Services Guide, December 2010, p. 3-4
• The medical record should also be complete and legible and include the date and legible identity of the physician who furnished the service. Further, Medicare requires that services provided be authenticated by the author of the medical record, with either a handwritten or electronic signature - Medicare Program Integrity Manual, Pub. 100-08, ch. 3, § 3.3.2.4
• If the signature in the medical record is illegible or missing, CMS asks the physician to “attest” to his/her signature - Medicare Program Integrity Manual, Pub. 100-08, ch. 3, § 3.3.2.4

If the physician does not provide this attestation statement, CMS then considers the claim to be insufficiently documented.

Stay tuned for Part 2 of this series, Lessons From OIG Audits of Physician E/M Services, which we’ll post tomorrow. Part 2 will provide details and best practices on how to ensure your organization is properly paid.

In the meantime, we thought you might also be interested in a recent webinar we hosted, titled, Enhancing Your Audit Plan with an External Audit: Keep the OIG Out of Your Organization. Watch the on-demand recording and download the slide deck by clicking the button below: