Texas Providers Should Expect Increase in Postpayment Audits of E/M Claims.

E/M Claims

(March 8, 2011): In February 2011, TrailBlazer Health Enterprises (TrailBlazer) reported the results of "widespread " probe reviews the contractor conducted of CPT Codes 99211–99215 related to Evaluation and Management (E/M) claims billed for dates of service 01/01/10 through 06/30/10. The frequency of E/M audits directed at Texas Medicare providers are increasing. Is your practice properly documenting E/M claims?

I. TrailBlazer’s Probe Review of E/M Claims:

The probe reviews conducted included the examination of 100 claims submitted by selected providers in Texas, Colorado, New Mexico and Oklahoma, along with 100 claims submitted by Virginia providers. Overall, TrailBlazer found that most of the E/M claims billed should not have been paid. In fact, the contractor found that very few of the E/M services billed to Medicare by Texas health care providers met the documentation requirements to qualify for coverage and payment. As TrailBlazer's report reflects:

The error rate for Texas / Colorado / New Mexico / Oklahoma health care providers was 91.32 %.

The error rate for Virginia health care providers was 51.43%.

II. Types of E/M Claims Errors Found by TrailBlazer:

TrailBlazer found the following problems when evaluating the documentation supporting the E/M services at issue:

"Documentation did not support Medicare’s requirements for the Evaluation and Management (E/M) service to be considered medically reasonable and necessary:

Inappropriate billing of an E/M service when only providing a non-covered service (e.g., acupuncture).

The chief complaint was absent, ambiguous or not addressed in the history, exam or Medical Decision-Making (MDM).

The chief complaint indicated the reason for the encounter was for administration of a medication, to have labs drawn or to receive the results for labs. None of these situations requires an E/M service.

In the absence of an acute problem, the frequency of E/M services billed per beneficiary for CPT codes 99212–99215 exceeded documented needs for management of stable, chronic conditions.

Documentation for the patient encounter did not provide a complete picture of the patient evaluation and management over time or the nature of the presenting problem.

Documentation of an exam was absent from the patient’s medical record.

Documentation of MDM was absent from the patient’s medical record.

The requested documentation was not received.

The documentation did not support the use of the 25 modifier (no significant, separately identifiable E/M service was documented):

Documentation did not support a separate or any E/M services rendered.

Inappropriate billing of E/M services with physician attendance and supervision of hyperbaric oxygen therapy, intravenous infusions and various physical therapy services."

In addition to these observations, TrailBlazer has outlined a number of other findings in its 02/08/11 report.

III. Recommendations for Texas Providers When Billing E/M Claims:

In light of TrailBlazer’s probe review findings, (91.23% error rate), the ZPIC assigned to this jurisdiction (Health Integrity) will likely be conducting widespread post-payment audits of Texas providers billing E/M services to Medicare. It is imperative that Texas providers examine their E/M documentation practices to ensure that claims are being billed properly.

Additionally, providers billing E/M services to Medicare should examine their current Compliance Plans and verify that this issue is included as a "risk area " to be regularly reviewed by the practice or clinic.

Robert Liles Healthcare Attorney

Robert W. Liles, J.D., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law. Liles Parker attorneys have extensive experience representing health care providers in connection with postpayment, E/M audits, and in compliance matters. Should you have questions regarding these issues, give us a call for a complimentary consultation. We can be reached at: 1 (800) 475-1906.