Medicare E&M Audits Coming

The Centers for Medicare & Medicaid Services (CMS) gave Region C Recovery Auditor Contractor (RAC) Connolly, Inc. the green light to begin auditing Medicare coding for CPT 99215  evaluation and management of an established patient  in physician offices in Texas and several other states.

Texas Medical Association Payment Advocacy Director Genevieve Davis said the association is trying to get information from CMS about where and when the Texas audits will begin. She said TMA is concerned about the timing of the audits since Novitas Solutions will become the new Medicare carrier for Texas in November.

TMA also is concerned about the service to be audited. E&M audits are subjective and require a lot of information and review to determine if the service is coded correctly, she said. Another concern is that Connolly will be able to extrapolate its findings based on a statistical sample of claims, which is not always an accurate assessment of a physician's coding and documentation.

TMA Payment Advocacy says you have options if Connolly selects you for an audit.

Besides Texas, Connolly conducts audits for CMS in 16 other states and territories.

For more information about the recovery audit program, email RAC[at]cms[dot]hhs[dot]gov.

TMA Ready to Help 

TMA offers several online courses and publications to help you avoid trouble. They also offer continuing medical education (CME) credit. They include:

  • Avoiding RAC Audits, which teaches you how to conduct a self-audit, what to do with your findings, and how to obtain buy-in for corrective actions (enter coupon code:ACTION to receive a $25 registration fee);
  • Fraud and Abuse Compliance, a seminar that addresses what constitutes fraud and abuse and how to steer clear of it in your practice; and
  • A new publication, Fraud and Abuse, which covers the basic ethical and legal tenets regarding health care fraud and abuse, and gives you a clear overview of how federal and state law enforcement can affect a practice.

For a complete list of offerings, go to the TMA Education Center a convenient, one-stop access to CME when you need it.

TMA's Coding Hotline can answer your questions. Call (800) 880-1300, ext. 1414.

TMA Practice Consulting advises you against waiting for a formal third-party or RAC audit. Be proactive. Find out if you or your practice is at risk for audit. TMA Practice Consulting has certified professional medical auditors and coders on staff to review physicians' documentation to determine whether the documentation guidelines are being followed, levels of service are correctly coded, and medical necessity is established. It also offers these services to help to make sure you code correctly and document what you've done:

  • Coding and documentation audits, comprehensive reviews of medical record documentation, identity opportunities for improvement, helping reduce your liability and risk of third-party audits;
  • Coding and documentation training provides an in-depth understanding of the coding and documentation guidelines and criteria for appropriate charge capture; and
  • Coding and documentation check-ups, abbreviated reviews of claims coding and medical record documentation, provide a glimpse into a physician's coding techniques.

Call TMA Practice Consulting at (800) 523-8776 for a proposal, or email[at]texmed[dot]org.

CMS also has resources for physicians. They include the Evaluation and Management Services Guide and Documentation Guidelines for Evaluation and Management Services. Physicians should be following these guidelines since auditors use when reviewing medical records. They're also the guidelines that EMR vendors should use when setting up physician templates. Physicians should make sure their EMR vendor does this.

The Department of Health and Human Services (HHS) reports that between 2001 and 2010:

  • Medicare payments for E&M services increased by 48 percent, from $22.7 billion to $33.5 billion.
  • The number of E&M services billed by physicians increased by just 13 percent, from 346 million to 392 million.

Based on the percentage of services billed for each E&M code, HHS found that physicians increased their billing of higher level E&M codes and reduced their billing of lower level, less complex and less expensive E&M codes.

CMS alleges that E&M services had the most improper payments of all Medicare Part B service types in 2008. This is likely one of the reasons E&M services are some of the most scrutinized and audited services. For some practices, E&M services may account for more than half of a physician's revenue; it is critical that you correctly code and document these services.

Action, Sept. 17, 2012

Last Updated On

May 13, 2016

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