Strategic Health Solutions has Initiated an E/M Claims Audit of 99214 and 99215

Is Strategic Health Solutions Conducting an E/M Claims Audit at Your Practice?

(August 15, 2013): Over the last few months, Strategic Health Solutions, LLC, a Supplemental Medical Review Contractor, appears to have significantly stepped up its post-payment audits of physicians and non-physician practitioners billing high level Evaluation and Management (E/M) codes. Strategic Health Solutions’ current audit push appears to be focused on E/M services provided to established patients on an outpatient basis, at the higher levels of CPT[1] Codes 99214 and 99215. According to Strategic Health Solutions, an analysis of Medicare claims data covering calendar years 2001 through 2010 has indicated that there has been a significant increase in the frequency of billing and payment for higher level E/M codes. The contractor has now initiated an E/M claims audit of providers found to have billed CPT codes 99214 and 99215 more frequently than their peers.

At its highest level, the Social Security Act governs whether Medicare will reimburse a health care for the E/M services provided to a qualified beneficiary. Under §1862(a)(1)(A) of the Social Security Act, Medicare will cover only services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or to improve functioning.[2]

Health care providers (such as physicians, nurse practitioners and physician assistants) choosing to participate in the Medicare program are required to follow and adhere to all applicable statutory and regulatory requirements governing the medical necessity, coverage, documentation and billing of E/M codes at the proper level.[3] Importantly, the primary documents to be used by health care providers when evaluating E/M services include the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.[4]

I. The OIG has Repeatedly Expressed Concern over the Wrongful Billing of CPT Codes 99214 & 99215:

For more than a decade, the Department of Health and Human Services, Office of Inspector General (OIG) and other regulatory authorities have expressed their ongoing concerns regarding “upcoding” – the improper coding of E/M services at a higher level than what was needed or what was found to be medically necessary in the care and treatment of a patient. Additionally, there have also been worries that “coding creep” may be occurring. Coding creep is essentially the steady, seemingly inadvertent, unsupported rise in the coding and billing of higher level E/M services by physicians and physician extenders. As OIG reported in May 2012:

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.”[5] (emphasis added).

In response to these findings, the OIG identified a number of remedial actions to be taken, two of which would include:

  1. The continuing education of physicians on the proper evaluation, coding and billing of E/M services.
  2. CMS contractors should be encouraged to review physicians’ billing for E/M services.

Strategic Health Services in one of several CMS contractors engaged to conduct a post-payment an E/M claims audit of services billed at the CPT code 99214 and 99215 levels.

II. Geographic Locations Affected by this E/M Claims Audit:

As a national Supplemental Medical Review Contractor, Strategic Health Solutions has been targeting physicians throughout the nation. In particular, we have received numerous calls from physicians in Maryland, including both a sleep doctor and an endocrinologist. Notably, one of Strategic Health Solutions’ offices is located in Baltimore.

III. Actions You Can Take Today:

We strongly encourage physicians, nurse practitioners and physician assistants to carefully evaluate the appropriateness of their E/M billing practices. Once assessed, you should compare your billing rates of higher level E/M claims with those of their peers in the same specialty area. This comparison can be made in a relatively easy fashion.

Should you find that your E/M billing practices appear to be higher than those of your peers, this is a sure sign that your coding of E/M services should be further analyzed. To be clear, due to a variety of factors (such as your care of a medically-complex patient population) your billing of CPT codes 99214 and 99215 may, in fact, fully meet applicable rules for coverage and payment. Nevertheless, it is imperative that you carefully review your coding to better ensure that your services are being properly coded and billed. Moreover, should you conclude that E/M services have been billed at too high a level, you must take immediate steps to report and pay back any Medicare overpayments that may have been received.

Robert W. Liles - Managing Partner - Liles Parker

Robert W. Liles, MBA, MS, JD; serves as Managing Partner at Liles Parker, a boutique health law firm representing health care providers around the country in connection with Medicare and private payor audits, investigations, compliance and transactional health care projects. For a free consultation regarding your case, please give Robert a call. He can be reached at: 1 (800) 475-1906.

  • [1] The acronym “CPT” stands for the phrase “Current Procedural Terminology.” The CPT coding system was first adopted in 1983, as a component of the Healthcare Common Procedure Coding System (HCPCS). Physicians and other eligible health care providers are mandated to use the CPT coding system to bill for E/M services.
  • [2] Social Security Act § 1862(a)(1)(A), 42 U.S.C. § 1395y(a)(1)(A).
  • [3] CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1. Accessed at on May 16, 2011. See also Appendix A.
  • [4]
  • [5] HHS-OIG Report titled "Coding Trends of Medicare Evaluation and Management Services," OEI-04-10-00180, (May 2012).