Part B Insider (Multispecialty) Coding Alert

Published on Thu Apr 27, 2006 PDF

Protect yourself from carrier audits with these handy tips

Watch out: Carriers are looking over your evaluation and management billing more than ever. If your claim falls outside the carriers' "bell curve" of typical billing practices, then you could find your head ringing.

When you bill high-level E/M visits, you should look for signs that your carrier's audit staff may find them an attractive target, says Deborah Grider, a consultant with Medical Professionals Inc. in Indianapolis, IN and president-elect of the AAPC National Advisory Board. Grider has been working with providers who have been hit with pre-payment E/M audits.

Many carriers look for the over-utilization of the higher E/M levels, for new patient, hospital admission or consult services, says Grider.
Example: If your physician always bills a level-three (99223) hospital admission, he or she may be at a higher risk of downcoding and/or audits, says Grider. Look for the warning signs that your E/M claims may appear to be upcoded, she advises.

Red flag: A physician bills a level-five office consult (99245) with a comprehensive exam and high-level of medical decision making (MDM). But if the physician's history doesn't contain enough detail, the carrier will likely downcode the claim.

Similarly, you're risking a downcode for a level-five visit if the history and exam are comprehensive, but the patient only has diabetes symptoms that are mildly exacerbating, and the physician only prescribes medication, says Grider.

Do this: Make sure your documentation includes "all data relative to the presenting problem," and that the MDM outlines the physician's assessment and plan of care completely, adds Grider.

Stay off the radar: Carriers look for physicians whose billing patterns are wildly different than others in the same specialty or geographic area, says Grider. They compare your billing to the "bell curve" of average physician E/M billing in your area or specialty.
If your pattern is different than the bell curve, it doesn't mean you'll be audited. It does, however, put you on the carrier's radar, Grider warns. You should compare your E/M billing to your carrier's data on a quarterly basis at least. And you should compare each individual physician's billing to the average as well, to see if one physician is an "outlier."

If one physician stands out as an E/M high-flier, review his or her documentation and make sure it supports the medical necessity for the levels billed. If not, you should help educate this physician on E/M documentation requirements, Grider urges.

Pay attention: Some codes carry a higher risk of audit than others, Grider explains. For example, consultation codes pay more than new or established patient codes, so they're more likely to attract attention. They also carry more documentation requirements, including a written request from the referring physician and a letter from the consulting physician, notes Grider.

Complaints: Sometimes your patients will complain to the carrier about the level of service your physician reported, which can trigger an audit. You should make sure to communicate clearly with your patients about services and procedures to reduce the chances of such complaints, says Grider.