Corporate Compliance

Tip: Compare your facility to others when performing an E/M audit

Compliance Monitor, April 8, 2009

To begin an evaluation and management (E/M) services audit, compare your facility with others in the area, says Andrei M. Costantino, MHA, CHC, CPC-H, CPC, director of organizational integrity at Trinity Health in Farmington Hills, MI.

CMS gathers data on physicians by practice, showing the types of E/M codes practices use the most. This information indicates how your physicians’ coding lines up with other practices and serves as a guide as to which areas to review.

“If it looks like all the docs in our area are billing 99213 and our doc is billing more 99214, we look at that and say, ‘Hey, that’s an outlier,’ ” Costantino says. “It’s not necessarily a bad thing; it’s just that that’s something the government is going to look at. We want to step back and say, ‘Let’s take a look and see if the documentation supports the billing of that 99214 code.’ ”

Some physicians will code conservatively, assigning the same low-level code for every visit in hopes of avoiding any attention from government auditors. Such actions are just as noncompliant as overcoding, Costantino says. “Whether you under- or overcode, it needs to be looked at on both sides,” he says.

This tip is an excerpt from the article “Know compliance risks before auditing” which appears in the April 2009 issue of the HCPro newsletter Healthcare Auditing Strategies. To learn more about Healthcare Auditing Strategies visit the HCMarketplace.

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