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RAC Audits of E/M Services Set to Begin in 15 States
Auditors to Target CPT Codes 99214, 99215
By News Staff
However, physicians in other states should be on alert, as well, because the E/M code audit process is scheduled to be expanded to the other three RAC regions.
CMS Makes Case for E/M Audits
- CMS' Recovery Audit Contractor (RAC) in RAC region three has been instructed to commence audits on high level evaluation and management (E/M) codes.
- The auditing contractor will focus on physicians' use of higher-level E/M codes, including CPT codes 99214 and 99215.
- RACs in the other three regions of the country will follow suit, with similar audits in the near future.
According to the OIG, it was able to look at Part B claims data and then identify individual physicians who frequently billed the more expensive and complex E/M codes, including 99214 and 99215, in 2010. However, the OIG did not make any determination as to whether the claims were appropriate.
The OIG said it identified 1,700 physicians who "consistently billed higher E/M codes in 2010." Physicians billing higher E/M codes were not grouped in any particular state or region and treated Medicare patients of similar ages and with similar diagnoses as physicians who coded claims with lower-level E/M codes.
AAFP Tracks RACs
The AAFP joined the AMA and other national organizations in voicing concerns about the "perverse incentive structure and burdensome nature" of both the Medicare and Medicaid RAC programs.
In a 2011 letter, the organizations asked CMS to, among other things,
- establish reasonable time lines for the request of information,
- include physician medical directors on Medicaid RAC staffs,
- create RAC websites and use them to post timely information, and
- employ certified coders to make coding determinations.
The OIG found that among physicians who consistently billed higher-level E/M codes, 19.8 percent were internists, 12.2 percent were family physicians, and 9.9 percent were in emergency medicine.
OIG Looks at EHRs and E/M coding
However, a separate OIG study does not support that argument. On June 21, the OIG released results of a study (19-page PDF; About PDFs) that looked at the use of EHRs in 2011 by 2,000 randomly selected Medicare participating physicians who provided at least 100 E/M services in 2010. Physicians were asked if they used an EHR to document services, and, if so, they were asked to provide the name of the system and state whether their EHR was certified.
According to a study summary, the OIG found that 57 percent of the physicians surveyed used an EHR at their primary practice location in 2011, and that three of every four physicians with an EHR used a certified system to document E/M services.
However, wrote the authors, "Although many EHR systems can assist physicians in assigning codes for E/M services, we found that most Medicare physicians manually assigned E/M codes."