Articles on Compliance Strategies

Medicare Watchdogs Intensify E/M Coding Scrutiny; New Audit Sources Are Available

Reprinted from the June 27, 2005, issue of REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

Medicare watchdogs have gotten very clever about auditing evaluation and management services, so providers might want to adopt some of their strategies, one expert says. Both regular Medicare auditors and enforcers are dogging evaluation and management (E/M) codes because they represent billions of reimbursement dollars.

The same goes for commercial payers, who are using sophisticated data analysis tools to detect billing anomalies for E/M services, says Georgette Gustin, a director of healthcare advisory services at PricewaterhouseCoopers in Indianapolis.

E/M services — core physician services performed in private practices, hospitals, nursing homes and every other setting — are the dominant Medicare Part B services, comprising more than 40% of them, she says. The top five codes submitted to Medicare, Gustin says, are E/M codes 99213, 99232, 99214, 99212, 99231. That makes them attractive targets for government auditors and enforcers.

For example, the HHS Office of Inspector General (OIG) regional office in Illinois did 797 different medical audits with computer surveillance in 2003, she says. The audits yielded $27 million in collections from physicians. OIG identified over 8,000 CPT codes as either time dependent, non-time dependent or Department of Public Aid-assigned, and then OIG designated a minimum time to each procedure code. Physicians who crossed the space-time continuum — which means their claims represented more than 12 hours of services in one day — were referred to the Medicaid fraud control unit, she says. With the Illinois OIG publishing this E/M crackdown on its Web site and annual report, other OIG offices may copy the successful initiative, Gustin says.

Another E/M audit project is spreading. CMS and Medicaid fraud control units (MFCUs) are joining forces to check whether the same provider billed for the same E/M service on the same day and to see who billed Medicare and Medicaid for more than 24 hours in a given day. After this program saved $58 million in California in 2001, CMS/MFCUs are taking it to Kentucky and Alabama, where they will be mining and matching Medicare and Medicaid E/M data from the same 24-hour period to look for anomalies, Gustin says. Projects are planned for Florida, Illinois, New Jersey, North Carolina, Pennsylvania and Texas.

There are lessons to learn from private payers, such as Humana Inc. and CIGNA, Corp., which mine data to uncover E/M upcoding. For example, in 2002, Humana began focused reviews of outlier physicians for high-intensity E/M claims (i.e., E/M claims that exceed 75% for the physician's specialty), Gustin says.

Private Payers Get Jiggy With It

Humana reviews eight high-intensity E/M codes: New patient exams (99204-99205), established patient exams (99214-99215), consultations (99244-99245) and emergency room services (99284-99285).

Wisconsin Physicians Service, the Medicare carrier for Wisconsin, Minnesota, Illinois and Michigan, found some alarming error rates in its E/M audits. In Minnesota, the overall error rate for CPT code 99232 was 51%, mostly for requested records not received from providers and for services not documented. In Michigan, the error rate for CPT code 99213 was 22.1%, also overwhelmingly for requested records not received.

CIGNA Medicare Administration, a Medicare carrier, as well as other Medicare carriers, have been conducting focused medical reviews of the top 30 CPT codes billed by specialty. "The top 30 codes are listed according to the carrier-allowed charges per 1,000 Medicare beneficiaries in the state. The state rankings are compared to national rankings for the same specialty along with comparing the carrier and national-allowed services per 1,000 beneficiaries," says Gustin. When carriers flag large disparities — such as 1.5 times more services or 1.5 more allowed charges per 1,000 beneficiaries — the auditors dig to figure out why there's an aberration.

Providers have long audited E/M coding. They have typically scrutinized five to 10 medical records per physician, comparing them to Medicare bell curve data. But now providers are reaching for new horizons. "There are so many resources you can use to develop sampling methodology," says Gustin, who spoke on E/M audits at a recent Health Care Compliance Assn. conference. "I don't want people to fall short and only use CMS bell curve data."

Here are some examples of other sources of E/M auditing data and guidance for sampling methodology:

• Comprehensive Error Rate Testing (CERT) reports. CERT is a major CMS program integrity tool used to calculate non-hospital claims error rates by contractor. But CERT is also an untapped source: (1) providers can scour CERT reports for patterns of troublesome codes and specialties that warrant E/M audit scrutiny; and (2) they can track and trend CERT letters. According to the fiscal 2004 CERT report, five of the top 20 upcoding errors were E/M services (99255, 99215, 99204, 99245 and 99205).
• Probe audit results by carriers published in carrier bulletins. For example, there is a nationwide probe audit of physical therapy codes (e.g., 97110). If you study bulletins from carriers across the country, it will be clear where to focus E/M audits. "Look for trends," she says.
• OIG corporate integrity agreements have specific formulas for conducting internal audits.
• CMS data. If you're a clever detective, there is higher-level data on the CMS Web site. One CMS Web page allows you to pull the percentage of total allowed charges for each CPT code.
  

Advertise With AIS

Privacy

Site Map