Doctors receive no training on coding, which makes them prone to fraud

How much attention do you pay to your Evaluation and Management (E&M) Coding practices?

E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide.

According to the Office of the Inspector General (OIG), Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments.  So it makes sense that among other things, the 2011 OIG work plan calls for:

  • Review of Evaluation and Management (E&M) claims to identify trends in the coding of E&M services. E&M claims will be reviewed to determine whether coding patterns vary by provider characteristics.
  • Evaluation of consistency of E&M medical review determinations to be sure the “documentation supports the level of service reported.”

Additionally, under the global surgery fee concept, physicians bill a single fee for all services that are usually associated with a surgical procedure and related E&M services provided during the global surgery period.  The OIG will review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee.

What if your practice has an Electronic Health Record (EHR) system?  That should ensure correct coding and documentation practices, along with the provision of quality care, right?

Not so fast.

Due to the 2011 EHR incentives involving EHR’s and meaningful use, government IT officials will be closely monitoring patterns of EHR use.  Medicare contractors have noted an increased frequency of medical records with identical documentation across services.  The 2011 work plan states the OIG will review multiple E&M services from the same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments.

In case you still assume physicians and other providers won’t be held accountable for their documentation of services, consider a case in Detroit, Michigan.  Detroit Medical Center (DMC) highlights the importance of provider coding and documentation patterns.  From January 2007 through September 2009, DMC billed for certain E&M codes when available documentation did not support the level of service being billed.  The Settlement Agreement in 2011 listed each of the individual physicians who had a relationship with DMC.

I’m not suggesting any physician or administrator was, or is ever knowingly involved in fraud or abuse activity.  E&M coding and documentation isn’t intuitive and most doctors receive little to no training on best practice coding and documentation.  As a physician who left clinical practice, I can vouch for my lack of training in this and other non-clinical areas.  Now, I consider it part of my job as a physician advisor/consultant to help other physicians with non-clinical, business-related issues.

Because ignorance doesn’t absolve us (or the administrators/managers that oversee a practice) from liability.

Michelle Mudge-Riley is President of Physicians Helping Physicians and recommends Code Blue Coding to help physicians with coding.

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  • soloFP

    I have been reading Family Practice Management and Medical Economics coding sections for around 10 years. In my residency, we started coding dx and procedure/E&M codes within the first month. Most of my colleagues have no clue how to code and think the billing agency will take care of it. Medicare says that the health care provider who provides the service is responsible for the level of care. I have found that most EHRs encourage over coding.
    Despite all this, you can give an office note to 3 professional coders and have 3 different levels of care recommended. I annually am audited with records by the Medicare PPO/HMO plans have only have had one note in question on average each year that the professional coders would have coded differently: each time it was undercoded. Interestingly the insurance companies consider it error and fraud to under or over code. Most insurance companies are not interested in the under coding, however, as they only want money back on over coding and never to this date have offered to give extra money to me on under coded claims.
    Private insurance companies wait at lease 90 days for record audits and 1 year or longer on Medicare plans to do the audits, so that I can not resubmit the claims and get paid higher for any undercoded claims. It is acceptable, however, for the insurance companies and Medicare to come in and request money back over a year later, if they find over coded claims. It definitely is not a level playing field and makes me question why we allow Medicare and insurance companies to self interpret the AMA CPT codes and have our services undervalued.


    Fraud…intentional deception.

    I think most docs, at worst, are guilty of inability to parse out the obtuse and obfuscating rules of billing and coding. Those that are systematically truly fraudulent should be dealt with severely. The rest of “recovery” is the fear of the witch hunt.

  • John Bierma

    As a clinic adminstrator and health educator, I see this whole mess a product of the AMA’s own design. I assume that CPT was a good faith effort to enshrine traditional fee for service into some kind of rational method of insurance billing. (according to the accounts of the history of CPT coding). Unfortunately, the whole system has been distorted over time in favor of those who perform procedures (specialists) at the expense of primary care. As a health educator, I sponsored medical coding classes and also as an adminstrator tried to make economic sense out of it. I have concluded unless someone can convince to the contrary that billing based on “time”, which is allowed by Medicare for all E&M codes for visits that consists predominately of counseling and/or care coordination, is the best for the provider and the patient. Many of the posts on this blog complain about the physician not being allowed by some “boogy man” to spend time talking to the patients. In light of the ability to code based on time, I cannot understand why physicians don’t just build strong relationship with patients by doing lots of counseling and care coordination. Can someone explain this for me? If you code based on time using the time for an established patient visit level 3, CPT 99213, which is the most frequently used code in primary care, then the pay per hour of physician time is very stable and predictable. For example, in the Physician Fee Schedule search at the national fee for 99213 for a clinic is $68.97.for 15 minutes ($4.60 per minute) when coded based on time, 99214 is $102.27 for 25 minutes ($4.09 per minute) and 99215 is $137.60 for 40 minutes ($3.44 per minute) still paying more for shorter visits. But if you took the 99213 as the average then your revenue per physician for a 6.5 hours of patient billable time is 60 minutes times $4.60 = $276 per hour times 44 weeks worked out of 52 is 32.5 hours per week = 1430 hours worked per year times $276 = $394,680. If your physicans did their own coding based on time in your EMR, then you SHOULD operate with no more than 35% overhead in a high rent district. This leaves $256.542 per physician for salaries and benefits. With the rural HPSA bonus of about 15% that gives you $38,481 more. While this is not the $400,000 to $800,000 specialist make, it may be livable when you can practice in a relaxed atmosphere spending all the time with the patient you want. I value others input on coding on time.

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