I’m shocked, shocked to find that physicians are billing higher levels of E/M services!

“She is the Level Four Queen of GI.”

Few were actually surprised to read the OIG report that showed that physicians of all specialties (and Non-Physician Practitioners) are billing higher levels of E/M services than they were ten years ago.  The OIG reviewed CMS data from the past ten years, and produced charts for each category of code to show this.  In addition, the OIG identified about 1700 clinicians with unusually high billing patterns. 

Let’s take the two issues separately.  I’ve purchased the E/M frequency data for the last ten years, so the OIG report didn’t come as a surprise to me.  Looking at established patient visits, there are fewer level two visits (99212) billed and more level four visits (99214) over the past ten years.   Why?  Find me a clinician who hasn’t attended a coding course in the last few years.  We are still using guidelines developed in 1995 and 1997, so medical practitioners have had plenty of time to learn them.  If you can’t find two different E/M cheat sheets in any office, you aren’t looking hard enough. Paper templates and using an EMR allow a clinician to document more than in handwritten or dictated notes.  The incidence of many chronic conditions has increased, so patients present with more problems, and want to address all of them at every visit.  It would be wrong not to mention that financial pressures or RVU based reimbursement didn’t effect coding as well.

So, yes, medical practices are billing E/M services at higher levels than they did ten years ago. 

The second part of the OIG study identified about 1700 clinicians who billed 95% of their E/M visits at the top two levels in that category of code.  (E/M services have three, four or five levels of service, depending on the category of code.) Think about that.  That means 95% of new patients were billed as 99204 or 99205, 95% of established patients were billed as 99214 or 99215, 95% of admissions were billed as 99222 or 99223—well, you get the idea.  The clinicians in this sample were high billers.  What specialty do you think they were?  The highest level billers in the sample were from Internal Medicine, Family Practice, Emergency Medicine, Nurse Practitioner, OBGYN and Cardiology.

The OIG recommended that CMS contact these 1700 clinicians and review their documentation.  The OIG also recommended that CMS step up its E/M oversight.  While CMS mostly agreed with the OIG recommendations, they pointed out that the average return on reviewing an E/M note was $43 and it cost between $30 and $55 to review an E/M note. CMS pointed out that there were other Part B areas that might have a higher priority, and presumably, rate of return.

What should a practice do?  Review E/M utilization of all clinicians, compare their profile with one another and the CMS norm.  (Contact me if you need the data).  Look carefully at any clinician who is billing the majority of their visits at the highest two levels in any category.  Then, decide if your auditing and compliance activities belong with E/M services or another area on the OIG Work Plan. 

6 thoughts on “Shocked

  1. Hi Betsy: What do we need to do to get the data for our providers here at Concord Hospital and Concord Hospital Medical Groups? Thanks

    Belinda Shaw, RHIT, CCS

  2. I’m shaking in my boots after reading your article. If we don’t have at least one Provider that is part of the 1700 I will be Shocked. I have been preaching the same thing for years; do what you feel is medically necessary for the patient, document what you did, and select an E/M based on your documentation. If they only listened better.

  3. Is it possible that some lower E&M visits have been displaced by increasing utilization of preventive/wellness (where minor issues are handled along with the preventive care), contributing to a higher representation of 4/5 codes in the mix?

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s