Health Information Management

Government lawsuit alleges systematic E/M upcoding

APCs Insider, June 27, 2014

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By Steven Andrews, Editor
The U.S. government filed a civil lawsuit against a national physician group practice last week, alleging the company engaged in systematic overbilling for federal E/M service reimbursement.
This follows two recent reports from the Office of Inspector General (OIG) demonstrating the increased scrutiny the government is directing toward E/M claims.
The lawsuit against California-based IPC The Hospitalist Company, which employs 2,500 physicians and other providers in more than 28 states, alleges that IPC encouraged its physicians to bill at the highest level regardless of the level provided. The suit also says that physicians who billed at lower levels were pressured to "catch up" to their peers.
The government is allowed to recover up to three times its damages, plus up to $11,000 per each false claim submitted.
The lawsuit highlights the importance of correctly coding and billing E/M services, which can be challenging even with the best intentions.
"We know where we stand when the boundaries are clear, but in today’s system, the same E/M data presented to different coding experts or auditors will invariably be interpreted differently," says Peggy S. Blue, MPH, CPC, CCS-P, lead instructor for HCPro's Medicare Boot Camp Physician Services, as well as an instructor for the Certified Coder Boot Camp. "It’s unavoidable."
In addition to adhering to the 1995 or 1997 E/M guidelines from CMS, providers should check with their MACs for details on how to deal with specific criteria, such as counting body areas and organ systems, or integrating EHR.
Facilities and practices have to come up with their own E/M criteria. They need to make sure the criteria is applied the same way across the entire facility/practice, and also that they need to make sure the criteria can be provided to auditors. If the criteria are created correctly and applied universally, that could reduce the risks of audit takebacks or lawsuits.

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