Optometry Coding & Billing Alert

Inspectors are finding higher use of high-level E/M codes.

If you examine your practice's 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 MAC begins forcing you to make that determination.

A recent study by the Office of the Inspector General (OIG) 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 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 six 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. Optometrists were in the top 15 of specialties billing high-level E/M codes most often. 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.

The increase in EMRs have also allowed physicians to correctly capture the work they perform during an office visit, and it may surprise them to see it should have been billed out at a higher level of service, notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., and Brooklyn, N.Y. "Learning to use an EMR system to document E/M services is an educational lesson for physicians all by itself in that it requires them to properly document all the work performed and understand how the E/M code assignment is determined," she says. "So many doctors that I've audited are really shocked to find they have been overcoding new patient E/Ms and undercoding established patient E/Ms."

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.