CMS approves RAC review of E/M services

Despite opposition from the American Medical Association, the Medical Group Managers Association and numerous state specialty societies, The Centers for Medicare & Medicaid Services has approved RAC review of E/M services.

Background

In May of 2012, the Office of Inspector General (OIG) released an executive summary concerning the coding trends of Evaluation and Management (E&M) services offered to Medicare patients. The study reviewed payments for E&M services from 2001 through 2010. The findings were as follows:

From 2001 to 2010, physicians increased their billing of higher level E/M codes in all types of E/M services. Among these physicians, we identified approximately 1,700 who consistently billed higher level E/M codes in 2010. Although these physicians differed from others in their billing of E/M codes, they practiced in nearly all States and represented similar specialties. The physicians who consistently billed higher level E/M codes also treated beneficiaries of similar ages and with similar diagnoses as those treated by other physicians.

The decision’s potential impact

Based on the recommendation of the OIG, The Centers for Medicare & Medicaid Services (CMS) has now agreed to allow the review of CPT code 99215, level five outpatient visit, by the RAC auditor, Connolly, in Region C. Although CMS has only approved the review of level five outpatient visits, the Connolly website calls this issue “Incorrect Billing of Evaluation and Management Claims C000912012,”which could be interpreted to mean Connolly will be performing a more inclusive audit of Evaluation and Management level reporting. This issue does affect all 17 states in the region.

Ongoing opposition

On Sept. 11, 2012, The American Medical Association sent a letter to CMS strongly opposing the decision to allow any Evaluation and Management audits. The letter explains, “Physicians who provide E&M care apply complex decision-making based on myriad clinical approaches, including research and review of patient medical history, analyses regarding appropriate medication, discussion of home situation and prescription distribution plan, preventive care planning, and many other variables. Because of the complexity of this type of care, it does not lend itself easily to medical review.”

The letter goes on to discuss the lack of RAC’s same-specialty physician review requirement, and the AMA’s lack of confidence that Connolly can perform these types of audits effectively. It is also noted that the CMS FY2010 Recovery Auditor Report to Congress reported a 46 percent change in favor of the provider after appeals. Given the complexity of E&M reporting, the auditing of these services will cause physicians and CMS the undue stress of erroneous recoupments and lengthy appeal processes.
We will keep you posted on any further developments on this issue.

CPT 99215 documentation requirements

Below we’ve included the medical record documentation required for CPT code 99215, as included in the Current Procedural Terminology 2011 and 2012, American Medical Association.

The medical record documentation for CPT code 99215 must meet the following criteria:

  • Must be legible;
  • Clearly identify the patient, date of service, and who performed the service;
  • Accurately report all pertinent facts, findings, and observations;
  • Include an appropriate diagnosis for the service provided;
  • Documentation must have a hand-written or an electronic provider signature. Stamp signatures are not acceptable.

CPT Code 99215, per day, for the evaluation and management of an established patient, requires at least two of these three key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of high complexity.

Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

CPT code 99205, per day, for the evaluation and management of a new patient, requires these three key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of high complexity.

Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.

Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

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