Health Information Management

News: MAC contractor identifies E/M billing errors

CDI Strategies, July 7, 2011

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Evaluation and Management (E/M) services accounted for $28 billion in Part B payments nationally from April 2009 to May 2010, according to a June 21 special message from NHIC, Corp., the MAC coordinator for region J14. Of these services, 8.4% were billed at the wrong code level, according to Comprehensive Error Rate Testing (CERT) data.

“We have all heard the statement, ‘If it wasn't documented, it wasn't done!’ This is as true for E/M services as it is for any other type of care a patient receives,” the notice states. “Documentation of E/M services should support the level of service [provided]. In general, documentation of each patient encounter should include:
  • Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
  • Assessment, clinical impression, or diagnosis
  • Plan for/of care
  • Date and legible identity of the observer
  • Documentation of the total length of time of the encounter if the level of service is based on counseling and/or coordination of care
  • Describe the counseling and/or activities to coordinate care”



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