Reminder: Medicare Has Approved The Auditing Of E/M Services… Be Sure Your Documentation Justifies The Code!

Last September, the Centers for Medicare and Medicaid Services (CMS) approved Virginia’s Medicare Recovery Auditor (RAC) – Connolly – to begin conducting audits of coding for evaluation and management (E & M) services in physician offices, specifically CPT code 99215.  As such, the plan was for Connolly to begin in October 2012 a complex medical review of CPT code 99215, from which Connolly will be permitted to extrapolate their findings based on a statistical sample of such claims.

The AMA sent a letter to CMS Acting Administrator Marilyn Tavenner strongly objecting to these audits and urging CMS to rescind approval of RAC review of E&M codes.  Among the complaints voiced by the AMA were the following:

• That “physician choices regarding appropriate code designation can be a subjective matter based on the complexity of the patient visit. Physicians who provide E&M care apply complex decision-making based on myriad clinical approaches… [and b]ecause of the complexity of this type of care, it does not lend itself easily to medical review.”
• Because “the RACs are not required to have same-specialty physicians review RAC determinations, we have no confidence that the RACs will be up to the task of understanding these variables or their clinical relevance.”
• “[T]he RACs have a low accuracy rate as it is: CMS’ FY2010 Recovery Auditor Report to Congress reported that 46 percent of the Medicare RAC determinations appealed were decided in the provider’s favor. RAC review of E&M codes will undoubtedly lead to erroneous recoupments and lengthy, expensive appeals for both physicians and CMS.”
• “Each E&M visit is different based on the unique needs of the patient. Assignment of levels of E&M services is based on six components…  Due to the variability and balance of these components from one visit to the next based on the needs of each patient, the use of the extrapolation method in an audit for comparison of visits among different patients has a high outcome probability of error and should not be used.”

Despite the AMA’s and state and specialty medical societies’ historic and unwavering opposition to the RAC audits of E&M services, there has been a recent increased pressure on CMS to review physicians’ coding of E&M services.  Specifically, the Health and Human Services Office of Inspector General issued a report in May on this topic that specifically urged CMS to encourage its contractors to conduct these reviews and “if CMS determines that inappropriate claims have been paid, it should take steps to recover those overpayments.”  

The take away for all providers – document, document, document….  Ensure that in the event that your E&M coding is questioned, your documentation will support your/your staff’s coding determinations. 

If you have any questions relating to this matter – or wish to discuss the elements that would qualify your office visit for a level 5 code, please do not hesitate to contact us at any time.