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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