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Coding Corner

Wolves at the Door: E/M Coding Now

As a regulatory analyst for 3M Health Information Systems, I spend a portion of each day reviewing regulatory changes and updates, Office of Inspector General (OIG) actions, Centers for Medicare & Medicaid Services (CMS) releases, and myriad healthcare industry news feeds. My goal is to track what the industry is up to from a regulatory perspective, and to determine how those changes are likely to impact physicians and hospitals. In the last few weeks, I read some startling news.

The University of Illinois Hospital and Health Sciences System and Mount Sinai Hospital in Chicago owe CMS $145 million in disproportionate share Medicaid overpayments "because they had overcharged poor patients," according to a Fierce HealthFinance news report Feb. 27. What's even more startling is the alleged overcharges took place 13 years ago. This is beyond the normal statutes of limitations for many acts, including tax evasion and some other felonies, but the OIG nevertheless strongly suggests that CMS collect the long overdue payments. CMS countered that it had not collected some of the balances because the state did not agree with the OIG audits.

Another stunning article reported Feb. 14 by HealthLeaders Media discussed the case of a respected surgeon who was found guilty of fraudulent coding on claims submitted between August 2002 and October 2003. The doctor was "acquitted of two counts of Medicare fraud but convicted of two counts of making false statements in connection with surgical (CPT®) codes submitted" on old claims. He is now serving a 10-month prison sentence.

The Association of American Physicians and Surgeons (AAPS) warns, according to the article, "physicians will now need to practice 'defensive documentation,' taking more time away from patient care in order to double and triple check operative notes." I prefer to call it clinical documentation improvement (CDI), but I agree with the AAPS: Documentation is more important than ever.

OIG Uses Data Analytics
The OIG released a report titled "Coding Trends of Medicare Evaluation and Management Services," which highlights, "between 2001 and 2010, Medicare payments for Part B goods and services increased by 43 percent from $77 billion to $110 billion." During the same time, CMS payments for E/M services "increased 48 percent from $22.7 billion to $33.5 billion." Note that E/M payments rose at a greater percentage than all Part B healthcare services combined. The OIG also warned that E/M coding "has been vulnerable to fraud and abuse. In 2009, two healthcare entities paid over $10 million to settle allegations they fraudulently billed Medicare for E/M services."

CMS uses claims data analysis to identify the types of E/M services that had the greatest number of improper payments for Part B services. This was done initially in 2008 and is continuing. The OIG's report is the first, among others to come, which will "determine the appropriateness of Medicare payments for E/M services and the extent of documentation vulnerabilities in E/M services." In fact, the OIG was able to identify specific physicians who consistently over report E/M services. They've identified 1,700 individual physicians who consistently bill higher-level E/M codes in 2010.

CMS agreed with the OIG suggestion to continually educate regarding accurate E/M assignment and to have the Medicare Administrative Contractors (MACs) perform close reviews of E/M services. CMS only "partially concurred" that the OIG should further investigate those individual physicians they have identified who bill higher E/M levels for "appropriate action."

The OIG's next move regarding E/M coding is anyone's guess, but if the history of their recent actions is a guide, assume that they will not drop the issue. I believe they're analyzing your claims as you read this article. If you have any concern about your practice's E/M coding or your hospital's E/M coding, it's time to take action.

Already a Target?
The above examples are concerning trends in enforcement. Clearly, the wolf is at the door. They know who you are and what you're doing. There is no way to determine if you are already one of the 1,700 they identified, but there are steps you can take to be ready for OIG investigation - just in case.

Look at your practice Policy and Procedures (P&P) manual. If you don't have one, now is the time to create one. If you have a manual already, when was the last time you reviewed your P&Ps for E/M coding or documentation? Review and update those policies now.

If you outsource coding, be sure to work with your vendor(s), and get their input and sign off on P&Ps that concern your direct relationship with them and their work product. Be sure that you have a clear understanding of who is responsible for coding accuracy.

Even small physician practices need to have P&Ps for operations. Hospitals are known for large manuals with many chapters and pages. You don't need to go to that extent, but if internal coding audits aren't part of your P&P, I suggest that you add them.

Perform Internal Documentation and Coding Audits
If you have more than one coder, ask them to do quality assurance (QA) reviews of other's work. Be upfront and explain why you're auditing and how it will work. Redact the protected health information, physician, and coder to decrease human nature's tendency toward preferences, and "re-code" the case. If you outsource, discuss with your vendor how they conduct coding audits, and ask for the results of those done for your physicians. After you have performed audits, compare the QA reviews, and discuss them with your coders.

Another audit technique is to provide the same case to all your coders. Ask them to independently review and code the case. Then, compare outcomes. Discuss outliers, and keep records of the audits.

An outside consultant also can perform documentation and coding audits, and hiring one is a good idea if you learn from an internal audit that you have documentation or coding challenges. Find a consultant with experience in CDI, coding, and auditing. Sometimes a report from an "outsider" will carry greater weight with your physicians.

All along, document every step you have taken and each improvement. If you have the misfortune of a visit from the OIG, you can show them your desire to comply with coding rules and all the efforts you have made toward continued E/M coding improvement.

Barbara Aubry, RN, CPC, CHCQM, FAIHQ, is a senior regulatory analyst at 3M Health Information Systems. She is responsible for analyzing CMS and other payer rules and regulations and communicating how the changes impact 3M customers. Aubry also creates and maintains data and is heavily involved in ICD-10 translation of National Coverage Determination (NCD) policies for CMS. Previously, she was the utilization review manager at Holy Name Hospital, director of peer review and audit for a privately owned company, and manager of the department of utilization management for an East Coast HMO. She has been AAPC certified for nearly 15 years.


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