How Can I be Comfortable with my E/M Documentation?

Home Provider Part B Publications 2007 Archives

Evaluation & Management (E/M) services are the majority of services billed by physicians and non-physician practitioners (NPP). Wisconsin Physicians Service (WPS) Medicare and the Comprehensive Error Rate Testing (CERT) contractor have identified documentation as the number one reason why Medicare either denies claims or requests refunds. So how do you know your documentation is OK? Look at the following scenarios:

You are on a dark street late at night and a police car pulls out behind you. You can react in several ways.

  1. If you are speeding, you can continue to speed hoping the police officer will not notice or will let you pass. This equates to providers justifying the regular use of high-level procedure codes based on statements such as "I'm a level 1 Trauma Center" or "I'm a specialist" or "Other doctors refer their sicker patients to me." Medicare does not consider any of these types of statements when evaluating documentation. Remember the documentation must support the medical necessity of the service and the level of service billed.
  2. You can hit your brakes and suddenly start driving 10 miles under the speed limit. This equates to providers billing a lower level of service that what they performed and documented for the patient. Medicare's responsibility is to pay claims appropriately. We should reimburse you for the medically necessary services you provide. Providers believe that by billing a lower level of code, Medicare will not request documentation. It is an error when Medicare pays a procedure incorrectly, whether that is under or over the services documented.
  3. You can turn off the road. This equates to providers who do not believe they should be required to provide this information. They are frustrated with the documentation requirement that they stop seeing Medicare patients. A provider has a right, obviously, to see the patient population he or she chooses. However, for most specialties, the Medicare population is a big percentage of a physician's practice. Accurate documentation supports the provider in numerous ways, not only for Medicare reimbursement.
  4. If in the above situations, the officer stops your car, you would be required to produce the paperwork such as license, registration, and insurance. When you reach into your glove box and all the necessary documents are there, it will not be long before you are on your way. If you were unable to produce these documents, then you have a problem. This equates to Medicare requesting documentation and the documentation is either not received or does not support the service. Make sure your front office staff can recognize requests for documentation and that you have a procedure in place for sending the information to Medicare. Please keep in mind that Medicare does not know your patients. The only information we have to make our determination is the documentation you submit. Medicare does not expect providers to write a book. We simply expect the information to show the medical necessity of the service and that the documentation supports the level of service billed.
  5. What about when the police officer decides that today is the day to stop all white mini-vans? You pull over to the side of the road and provide your license, registration, and insurance. This equates to audits that Medicare performs on particular procedure codes. We will request documentation from multiple providers for the identified codes. If your documentation supports the medical necessity and the level of care code billed, then you do not have anything to worry about. Medicare will look at the documentation and determine that you billed and we paid correctly.

WPS Medicare has published multiple articles concerning documentation. These include the following (not a complete list):

The Centers for Medicare & Medicaid Services (CMS) has multiple resources to assist providers in understanding the need for documentation.


Page Last Updated: Tuesday, 15-Jul-2008 10:45:23 CDT