Self-Auditing Related to Evaluation and Management (E/M) Coding Errors

In 2011, E/M services continue to account for a significant portion of WPS Medicare's Comprehensive Error Rate Testing (CERT) errors. For providers to ensure that claims are submitted appropriately, an ongoing evaluation process is important. A self audit is an excellent way for a physician practice to ascertain if any problem areas exist which may warrant further education or corrective actions. A complete and successful self audit evaluation includes both a standards and procedures review and a claim submission audit.

To access information about performing physician self-audits, please refer to Final Compliance Program Guidance for Individual and Small Group Physician Practices, located on the Office of Inspector General (OIG) websiteAdobe Portable Document Format.

For other Compliance Program Guidance, including guidance for specific provider/supplier types, please refer to this OIG web page(external link). The purpose of this article is to share general and service-specific tips aimed at reducing CERT errors assessed for E/M services.

General Tips to consider when performing a self-audit of E/M Services

  • Medical necessity is the overall criterion for payment in addition to the specific technical requirements of a CPT code.
  • It is not appropriate to bill a higher level of E/M service when a lower level of service is warranted.
  • The volume of documentation should not be used to determine the level of service.
  • Documentation must support the level of service reported.
  • In order to maintain an accurate record, document during or shortly after rendering the service.

Subsequent Hospital Care

All levels of subsequent hospital visits include review of the medical record(s) as well as review of diagnostic studies and changes in the patient's status (i.e., change in history, physical condition and response to management) since the last assessment by the physician.

Tips to consider when performing a self-audit of Subsequent Hospital Care
  • The documentation of a subsequent hospital visit must include evidence of the provider's presence at the patient's bedside.
  • The documentation for the level of service billed must contain at least 2 of the 3 Key Components of a subsequent hospital visit at the level, according to the applicable CPT description.
  • There must be evidence in the documentation of the subsequent hospital service to support the medical necessity of the visit.

Established Office Visits

Codes are used to report evaluation and management services provided in the physician's office or in an outpatient or other ambulatory facility. A patient is considered an outpatient until inpatient admission to a health care facility occurs.

Tips to consider when performing a self audit of Established Office Visits

  • The documentation for the level of service billed must contain at least 2 of the 3 Key Components of an established office visit at that level, according to the applicable CPT description.
  • There must be evidence in the documentation to support the medical necessity of the office visit.

Your cooperation in proper documentation and billing of Medicare services is needed to reduce improper Medicare payments and meet the Centers for Medicare & Medicaid Services' (CMS) national error rate reduction goals. Continued CERT error findings may result in additional review by CMS, WPS Medicare, Recovery Audit Contractors (RAC) or Zone Program Integrity Contractors (ZPIC).

Visit our WPS Medicare Evaluation and Management Services web page for additional resources to assist with the proper documentation and billing of these services.

Page Last Updated: Thursday, 15-Dec-2011 11:59:48 CST