The data shows a sharp increase in level 4 and level 5 E/M utilization over the last decade. The study’s authors don’t point to any evidence of improper billing, but they do send the names of the 1,700 highest-billing physicians to CMS and recommend that CMS send those names to the MACs for review and possible recoupment of any overpayments.Coders, have you come across any practices that might fall into that high-billing territory and if so, do you see any habitual billing errors at those practices? Also, should those practices that have always played it safe see this report as a sign that they should continue to do so?
The increased adoption of EMR's may be leading primary care and internal medicine practitioners to code at a higher level, with the assurance that they have a structured, complete note. This may justify an increase in their coding and they are no longer undercoding and losing the practice money by playing it safe.
The other side of the coin is that use of EMR templates may lead to cloned notes, creating a higher level of documentation that is not always supported by medical necessity. Remember, these tools can help in creating text, but each note should be authentic. Every element of History of Present Illness (HPI) must be documented personally by the provider, and every element of Review of Systems (ROS) and Physical Exam should be justified (for medical necessity) in the HPI. Risk based coding puts the emphasis on the type of medical decision making, which should always agree with the level selected.
The best way to prevent fraud is to have an annual chart audit performed by a qualified, independent auditor. The American Academy of Professional Coders has a certification program and exam for Certified Professional Medical Auditor (CPMA) to ensure understanding of the criteria for chart auditing and provider feedback. To learn more, contact Nancy Enos at firstname.lastname@example.org