The evaluation and management codes auditors focus on

November 20, 2014

Becoming familiar with the details of evaluation and management billing codes can reduce your chances of being audited.

Q: We know that evaluation and management (E/M) codes are being scrutinized during insurance auditor reviews. Which codes are auditors focusing on?

A: If you are billing 99215, 99223 and 99222, be sure to read the latest information released by Comprehensive Error Rate Testing (CERT). Incorrect coding of E/M services continues to be an area of concern as demonstrated by recent CERT claim reviews.

Wisconsin Physician Services’ (WPS) Medicare analysis of recent CERT findings in J8 reveals three E/M CPT codes (with fifteen or more services reviewed in the sample) that were incorrectly coded at a rate of at least 44%.

To avoid being part of these statistics, take some time to brush up on E/M coding and perform a self audit. Although this is a specific example related to WPS, excessively billing these high-level E/M codes will trigger an audit by any auditing entity across the country.

The accomanying chart illustrates these procedure codes and the percentage of cases for which the medical records submitted did not support the level of service billed.

The answer to this reader’s question was provided by Renee Dowling, a coding and billing consultant with VEI Coding Consulting Services in Indianapolis, Indiana. Send your practice management questions to medec@advanstar.com.