| Why Is It Important?
Medical record documentation can reduce many of the "hassles" associated with payment for claims; it serves as a legal document to verify the care
provided.
Documentation establishes which level of E&M coding represents the component
services in the history, examination, and plan of management.
The level of service provided must be reasonable and necessary to the presenting
complaint. |
What Is Its Impact on
CERT?
(Comprehensive Error Rate Testing)
E&M services are the top contributor to CERT errors on reviewed
claims. CERT data indicates that high-level E&M services for initial,
subsequent, and consultative services have frequently been cited as "up-coded"
by the provider and therefore paid by the Medicare contractors incorrectly. A small but
significant contributor to the error rate are claims on which providers have
"under-coded" E&M services. For more information on CERT,
visit us at http://www.empiremedicare.com. |
What Is
Empire Doing?
- 1995 and 1997 AMA E&M guidelines are available on Empire’s Web site:
http://www.empiremedicare.com.
- Empire is responding to CMS’s directive on correcting the E&M error rate
through education and review initiatives.
- Selected E&M codes may now be subject to prepayment edits that may
include frequency, diagnosis, and provider specialty.
- Post-payment audits for FY 2004 will focus on E&M billing patterns that appear
unusual and/or aberrant.
|
What Can
You Do?
- Don’t underestimate or overestimate your services; simply document all the
components of your service accurately.
- Consider template tools that represent the levels of service you frequently render.
- Request a Comparative Distribution Report (CDR) on your practice to compare your E&M
usage patterns to those of your peer group.
E-mail your request to: nybprov@empireblue.com for New York or njbprov@empireblue.com for New
Jersey.
- Use the above e-mails to request a group seminar delivered by our professional staff on
appropriate E&M coding.
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