OIG probes physician Medicare billing for office visits

Federal investigators single out nearly 1,700 physicians for billing a relatively high number of costly evaluation and management codes.

By Charles Fiegl amednews staff — Posted May 24, 2012

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Physicians are billing Medicare for far more intensive evaluation and management services than they did a decade ago, according to a Dept. of Health and Human Services Office of Inspector General report released in May.

Use of the two highest-level codes for established patient office visits has increased by 17%, as doctors have billed Medicare for fewer low- and mid-level codes from 2001 to 2010, the OIG said. Utilization of the high-level code for billing an emergency department visit also has risen 21%, while the top code for subsequent inpatient hospital care has increased 9%.

The OIG concludes in the report that several factors have led to these increases, including a boost in the overall number of services provided to patients and the average payment for evaluation and management services. “However, changes in physicians’ billing of E&M codes also contributed to this increase,” the report states.

The inspector general did make note of aberrant billing patterns during its review and sent the Centers for Medicare & Medicaid Services a list of 1,669 physicians who billed many more complex and expensive codes than their peers. The Medicare agency will forward the list to its contractors and direct them to focus on the top 10 billers in each jurisdiction for further review, according to a March 28 memo from acting CMS Administrator Marilyn Tavenner.

Increased billing of higher-level evaluation and management services is not surprising, said Betsy Nicoletti, a physician practice coding consultant and auditor based in Springfield, Vt. Doctors are well accustomed to evaluation and management guidelines, and there is no shortage of billing education and training opportunities for physicians. Electronic health records also have made it easier to meet billing requirements.

“We have all known about ‘code creep’ for a while,” she said. “Physicians in all specialties have moved to coding higher-level codes.”

The health professionals singled out in the report had billed high-level codes at least 95% of the time and could find themselves in trouble with the government, Nicoletti said. The three specialties with the largest percentage of physicians using high-level codes were internal medicine, family practice and emergency medicine.

Low-level and mid-level codes represented nearly 60% of established patient office visits billed in 2010, the report said. The high-level codes made up the remainder of the office visits billed.

CMS concurred with OIG’s recommendations in the report, Tavenner said. The Medicare agency will continue its education and outreach efforts to ensure correct physician billing. It also will share the report with Medicare administrative contractors, which process claims for services.

The Medicare agency plans to publish its own report targeting 5,000 physicians who billed high-level evaluation and management services consistently. The report is not intended to be an indication of fraud. “The intent is to be proactive and provide statements that will support helpful insights into physician coding and billing practices,” Tavenner said. That report is scheduled for release in June.

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