I’m going to start out today’s post with a confession of a personal shortcoming. I am much more dynamic on paper than I am in person. When I discuss a subject face-to-face with people, I have a tendency to obsess on one topic, much to the detriment of a random listener. I tend to blurt out thoughts without thinking, and based on my fund of bar knowledge, some of those random thoughts are downright frightening and have led to bans in several social circles across the United States.
There are some issues from which I squeeze the life in print, as many of my regular readers will certainly attest. If I had to select one topic which I have revisited more than others in my professional life (restricting our universe to the world of health care), it would be the billing and documentation of evaluation and management (E/M) services. Thanks to the majesty and splendor of the OIG Work Plan, I get another opportunity to write about it again today.
When the latest Work Plan was released last October, the OIG indicated that they would be reviewing trends in E/M coding for claims submitted between 2000 and 2009. In particular, the work plan stated that the OIG would “also identify providers that exhibited questionable billing for E/M services in 2009″. This morning, as I was searching the macabre depths of my mind for today’s topic, I received an e-mail stating that this review has been conducted and finalized.
There were two slight changes from the Work Plan and the released report, that being that the years of E/M data being reviewed was 2001-2010, and the identification of physicians with aberrant patterns being based on 2010 data. The findings of the report should come as no surprise to anyone who has been involved in medical billing consistently over the last decade. In the years surveyed, physicians “increased their billing of higher level E/M codes in all types of E/M services”. The analysis of the billing data identified approximately 1,700 physicians “who consistently billed higher level E/M codes in 2010″. Based on the report, the OIG recommended continued education, encouraging contractors to review physicians’ billing for E/M services and to commence review of physicians “who bill higher level E/M codes for appropriate action”. For those not studied in Apparatchik language, that means audits. Dr. X, meet Mr. ZPIC.
For the last 30 years, physicians in private practice have been feeling the reimbursement squeeze from government and commercial payers. In this environment, the physicians who care most about their reimbursement have been searching for ways to stop the bleeding. One of the easiest ways to do this is to increase reimbursement for the most common service of the practice, which is the face-to-face encounter with the patient. As a result of this philosophy coming to the fore, a cottage industry of consultants promising to increase reimbursement for E/M services by “strengthening” documentation has popped up, often focusing too much on “bullets” and not enough on medical necessity. In the world of the electronic medical record, this type of approach by practices is fraught with risk, especially if the physician is more receptive to a financial message rather than a message centered around compliant documentation. With ICD-10 poised to be shoved down our throats like a Turkish scimitar, documenting for reimbursement is a habit that is best broken sooner rather than later.
In the eyes of CMS and the OIG, the roughly 1,700 providers identified as outliers by this OIG analysis are about to have a rude awakening. Having reviewed tens of thousands of pieces of E/M documentation in my career, and having seen nine years of CERT results that have consistently identified high level E/M services as being coded improperly, there is absolutely no excuse for not knowing the documentation rules for E/M services. I have heard every physician canard (“…but I spend a lot of time with my patients…”, “…but my patients are sicker than others…”, “…these rules are so arbitrary…”, “…how am I supposed to keep my doors open…”, etc.) multiple times from multiple sources, and none of them make sense if your documentation of services is not a true reflection of the scope of the patient encounter. From personal experience, I can tell you that the instances where assumptions made by physicians about the care they are rendering being accurately reflected in their documentation upon initial review are few and far between.
Those of us who exist on the side of physicians have been waiting for the RAC contractors to announce their entry into the E/M universe. The RACs are surrounded on all sides with evidence from other audit entities that E/M services should be targeted. Based on the poor quality of the RAC work product up to this point, it is something of a blessing that the RACs have stayed on the sidelines. There should be no illusions that the RACs will continue with this indifference indefinitely.
I have written and spoken about E/M services in one way, shape or form on just about every day of my health care career. Those who know me are sick of hearing me talk about it, and future acquaintances will respond the same way given time. The OIG report is but another warning shot across the bow of providers who have been taught to game the system through creative coding and documentation techniques. My wife can tell you that I often repeat myself, but this is one topic that must be consistently reiterated based on rampant errors that exist.