Home News & Events Billing & Compliance Alerts OIG Zeros-In on Physicians with History of High-Level E/M Claims
OIG Zeros-In on Physicians with History of High-Level E/M Claims PDF Print E-mail

OIG Zeros-In on Physicians with History of High-Level E/M Claims
By Justn Vaughn, M.Div, CPC
Director of Compliance


The Office of Inspector General (OIG), the “watchdog” agency of the U.S. Dept. of Health and Human Services, has released a report indicating that physicians are reporting high-level evaluation and management (E/M) codes more frequently for all types of patient encounters.  As a result, Medicare payments for E/M services increased 48% during the decade ending in 2010.

In its analysis of the 2001-2010 period, the OIG identified 1,700 providers “who consistently billed higher-level E/M codes,” in contrast to their colleagues who treated similar patients but with lower-level E/M claim submissions.  The “outlier” physicians billed the two highest codes within a code set at least 95% of the time.

Though the OIG “did not determine whether the services billed by physicians who consistently billed higher level E/M codes were inappropriate or fraudulent,” there is nevertheless an implication within the OIG report that the shift in E/M coding patterns may, in part, be due to fraud or abuse.  In response to the OIG’s report and recommendations, CMS has advised that it will take the following actions:


  • Continue to educate physicians on proper billing for E/M services.
  • Encourage Medicare contractors to review physicians’ billing for E/M services.
  • Review physicians who bill higher-level E/M codes for appropriate action.

Since the OIG has already shared with CMS its list of the 1,700 providers determined to be overly aggressive in the billing of high-level E/M encounters, pain management physicians would do well to consider the following:

  1. Often, older patients with multiple problems represent the great preponderance of your clientele.  Accordingly, the very nature of your practice may lend itself to higher-level E/M coding on a more frequent basis when compared with other specialties.  Nevertheless, the nearly exclusive billing of level 4 and 5 E/M services will put you on the OIG’s radar, which may, in turn, trigger a CMS audit of your records.  Therefore it would behoove you to shy away from the routine indication of level 4 and 5 on the superbill, and instead perform an individual assessment of each case to determine if the patient’s condition truly justifies that level of service.  For example, if the patient is coming to see you for a hangnail, you have no choice but to bill a very low-level E/M—regardless of how many documentation bullets you hit.  The nature of the presenting problem is key in assessing code level.
  2. Where the patient’s condition and your level of service truly do warrant the billing of level 4 and 5 E/M claims, you should redouble your efforts to adequately support such high-level coding with sufficient documentation of the history, exam and medical decision-making, as explained and illustrated in CMS’s 1997 Documentation Guidelines for Evaluation and Management Services (which can be found on the CMS website).  Many doctors use a “cheat sheet” or laminated chart—based on this CMS document—to help them more easily determine the billable E/M level as indicated by their documentation of the patient visit.

Since the government has discovered a significant increase in E/M payments over the last decade, and has identified specific providers with a history of routine high-level claims, chronic pain providers should be on the alert, and should adjust their billing and documentation habits where necessary.  After all, it may be your practice the feds are watching.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.


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