How to avoid E/M errors and denials

The Centers for Medicare & Medicaid Services (CMS) says approximately 15 percent of evaluation and management (E/M) services are improperly paid and accounted for 9.3 percent of the overall Medicare fee-for-service improper payment rate in 2014. To help you avoid improper payment of your E/M claims and prevent payment denials, CMS has released a new fact sheet of compliance tips for E/M services.

According to the fact sheet, E/M claims are typically denied for two reasons: incorrect coding, such as the code not matching the documentation, and insufficient documentation, which can include a lack of a physician signature or no record of the extent and amount of time spent in counseling and/or coordination of care when it is used to qualify for a particular level of E/M service.

To prevent your E/M claims being denied, CMS recommends a number of strategies. First, in addition to the individual requirements for billing a selected E/M code, you should also consider whether the service is “reasonable and necessary.” For example, while it is possible to provide and document a level 5 office visit for a patient with a common cold and no comorbidities, it is unlikely that anyone would consider that level of service reasonable and necessary under those circumstances.

Another strategy is to remember the following key variables when selecting codes for E/M services:
•    Patient type (new or established)
•    Setting/place of service
•    The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (i.e., the number and type of the key components performed).

Finally, the fact sheet emphasizes the need to obtain the necessary physician/non-physician provider signatures. You can find links to additional CMS resources and references at the end of the fact sheet.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians