OIG to Send CMS Names of 1,700 Docs who Overbilled High-Level E/M Codes

Written by on July 2, 2012 in Features - No comments
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By Suzanne Leder, BA, M.Phil., CPC, COBGC, certified ICD-10 trainer and Torrey Kim, MA, CPC, CGSC, editor-in-chief of Part B Insider

If you examine your practice’s evaluation/management (E/M) trend line, does your frequency of reporting high-level E/M codes increase dramatically over the years? If so, you should determine the reasons why, before your Medicare administrative contractor (MAC) begins forcing you to make that determination.

A recent Office of Inspector General (OIG) study found that physicians increased their billing of higher-level E/M codes across all categories (inpatient, outpatient, etc.) between 2001 and 2010. In fact, the OIG sent Center for Medicare and Medicaid Services (CMS) a list of 1,700 physicians who were identified as “consistently billing higher-level E/M codes in 2010.” The report results were summarized as follows by the OIG in its report, “Coding Trends of Medicare Evaluation and Management Services,” which was published on May 9.

Outpatient: For outpatient services, the report noted that a shift was seen “in billing from the three lower-level E/M codes to the two higher-level codes. Combined, physicians increased their billing of the two highest-level E/M codes (99214 and 99215) by 17 percent” over the study period.

Inpatient: When it came to hospital visits, the OIG noted that billing the lowest code (99231) decreased 16 percent, whereas billing 99232 increased 6 percent and 99233 increased by nine percent.

Emergency: The shift was even more pronounced among emergency department visits, the report stated. During the study period, physicians decreased how often they billed the four lowest codes (99281-99284), but increased billing the highest code (99285) by a startling 21 percent.

These Specialties did the Most Damage

According to the OIG report, certain specialties seemed to report more high-level codes than others. Among the physicians who consistently billed the two highest-level E/M codes were internal medicine, family practice, emergency medicine, nurse practitioners, ob-gyns and cardiologists.

Specialties who billed the two highest-level E/M codes the least often were hematologists, cardiac and thoracic surgeons, surgical oncologists, pain management physicians, intensivists, hand surgeons, and allergists, among others.

High-Level Codes Don’t Necessarily Equal Fraud

Many reasons exist that could cause a practice to legitimately begin coding more high-level E/M services than in the past. For instance, the practice may have begun seeing a more complex patient population who have more chronic problems that require intense management. Or the practice may have been audited and discovered the physicians were downcoding claims, so now the physicians are correctly coding based on the documentation, which warrants more 99214s and 99215s.

If you fit into one of the legitimate billing categories such as these, you shouldn’t fret the new OIG study. If, however, you aren’t sure how your physicians arrive at their E/M codes, it’s time to offer a quick education session at your practice.

The OIG recommends coding education as the number one priority following the results of this report, and also encouraged MACs to review physicians’ E/M billing patterns to avoid improper payments. “CMS should conduct additional reviews of physicians who consistently bill higher level E/M codes to ensure that their claims are appropriate,” the OIG recommends. (To read the complete report, visit http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf)

Your Top 3 Hospital E/M Billing Questions Answered

Can you navigate the intricacies of inpatient E/M services? Check these expert solutions. You may be able to select outpatient E/M codes (99201-99215) with your eyes closed, but inpatient E/M coding can be more tricky. With the OIG scrutinizing E/M billing like never before, you should consider these commonly asked questions to get the lowdown on how to report your hospital services.

Physician Presence may Dictate Code

Question: Our physician saw a patient in the office, and then admitted her to the hospital later the same day. Can we bill for the office visit and the first day of admission, or do we just bill for the hospital stay?

Answer: The answer depends on whether the physician sees the patient on the same day in the hospital.

Scenario 1: If the physician sees the patient in the hospital on the same day he saw her in the office, you’re looking at two face-to-face visits on the same date. Report only the appropriate initial hospital care code (99221-99223, initial hospital care, per day, for the evaluation and management of a patient…). According to current procedural terminology (CPT) coding guidelines, all initial hospital care services that begin in another place of location (such as the physician’s office) should be combined and coded using the appropriate level of initial hospital care. Since the 99221-99223 code will include the E/M provided in the office, you’ll report an initial hospital care code that includes the work done in both sites of service; this may lead to coding a higher level of initial hospital care than if you were considering the hospital services alone.

Scenario 2: If, however, the physician does not see the patient in the hospital until the next day, bill each encounter separately. Choose the appropriate office visit code (99201-99205, office or other outpatient visit for the evaluation and management of a new patient …) or 99212-99215(office or other outpatient visit for the evaluation and management of an established patient …) for the office visit on day one. Then add an initial hospital care code from 99221-99223 for day two, when the physician sees the patient in the hospital for the first time.
Remember that CPT uses initial hospital care codes to describe the first hospital inpatient encounter by the admitting physician. After that, you’ll report subsequent hospital care codes, 99231-99233 (subsequent hospital care, per day, for the evaluation and management of a patient…), until the date of discharge. When the physician discharges the patient, you’ll submit the appropriate hospital discharge day code, 99238 or 99239.

Document Full Inpatient E/M

Question: Our physician’s documentation did not meet the minimum requirements for an initial hospital visit (99221-99223). Therefore, can we bill a subsequent visit (99231-99233)?

Answer: The answer depends on whether your physician was the admitting physician of record, or whether he simply provided a consultation during the patient’s hospital stay. Typically, the admitting physician cannot report a subsequent care code for his first visit with the patient. If your physician admitted the patient to the hospital and did not document enough for even the lowest-level initial hospital care code (99221), you should offer him pointers from an educational standpoint on how to appropriately code for this service. If he can’t bill anything for his initial visit, you’ve written off about $100 in potential reimbursement (which you could have collected if he’d documented enough for 99221). However, if another physician admitted the patient to the hospital and called your physician to provide a consult on the patient’s condition, you can report a subsequent hospital care code for your consultant’s services.

Why: CMS changed the requirements for who can bill a subsequent hospital care code after Medicare stopped recognizing consult codes for payment in 2010. According to Transmittal 2282, dated August 26, 2011,

In black and white: “Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241-99255) prior to Jan.1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay,” the transmittal reads.

It further notes, “Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.”

Because the transmittal referenced above was written to explain how to code in the absence of consult codes, you should apply this rule to your physician’s consultation services and not to the rules guiding the admitting physician of record.

Eight Hours may be the Magic Number for Same-Day Admit, Discharge

Question: Our general surgeon admitted a patient to the hospital at 10:30 a.m., and later that day another general surgeon from our group discharged the patient (at 3:30 p.m.). The admitting physician wants to bill a 99223 and the discharge physician wants to bill a 99217. Which code(s) should each physician report?

Answer: The answer to your question depends on several factors. First, you must determine whether the patient was admitted to inpatient status or to observation. That will help you at least review the appropriate code range. It appears that one of your physicians wants to bill an inpatient code (99223) whereas the other wants to bill a code from the observation range (99217). Therefore, it looks like even the physicians didn’t clearly understand whether the patient was in the observation unit or inpatient.

If you bill from the wrong section, it will impact you from not only a correct coding standpoint, but also possibly from a compliance standpoint, since initial inpatient codes reimburse approximately 3.5 percent more than initial observation codes.

If you find that the patient was in observation care, the second issue you must consider is the amount of time that the patient spent in the hospital (five hours). When coding this case, your eyes may go to the 99234-99236 (observation or inpatient hospital care, including admission and discharge on the same date), but you should avoid this section. Why? Medicare requires the patient to be in observation care for a minimum of eight hours to justify reporting this code.

In black and white: According to CMS Transmittal 1466, dated Feb. 22, 2008, “When a patient is admitted to observation status for less than eight hours on the same calendar date, the physician shall report a code from CPT code range 99218-99220.”

Therefore, if it’s an observation patient, you should report a code from the 99218-99220 series.

Important: No matter what code you select, you should only report one code to represent both physicians’ time with the patient, since they both work for your group and are the same specialty.

In black and white: “Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician,” CMS says in Section 30.6.5 of the Medicare Claims Processing Manual. “If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.”

 

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