Common Evaluation And Management (E/M) Services Coding Errors

One of the recurring problems facing healthcare facilities is incorrect coding of Evaluation and Management (E/M) Services.  The recent CERT (Comprehensive Error Testing) claim review analyzed by WPS Medicare reveals that within the fifteen or more services reviewed in that sample, three E/M CPT codes had been coded incorrectly in at least 44% of the total bills raised.  Given below is the CERT error examples along with the percentage of errors where the levels of service billed were not supported by the medical records submitted.

CPT Code 99215

The code covers office or other outpatient visit for the evaluation and management of an established patient.  This code requires at least two out of these three components:

1. Comprehensive history
2. Comprehensive exam
3. Medical decision making of high complexity

Of the total claims submitted between 07-01-2012 and 06-30-2013, 78% of services were coded incorrectly.  Here are some examples of CERT errors for CPT code 99215.

While the code requires two out of the three components (as above), the documentation submitted supports CPT 99213. This code requires two of these three components – EPF (expanded problem focused) history, comprehensive exam and medical decision making of low complexity.

Office notes submitted state Problem Focused History (discussing an abnormal echocardiogram), comprehensive exam and a Moderate Complexity of Medical Decision Making. This supports CPT code 99214 and not 99215.

Detailed History (History of present illness (HPI) and review of systems (ROS) as per the E/M guidelines of 1995 and 1997, Comprehensive exam and moderate complexity medical decision making as per 1995 and 1997 E/M guidelines, supports CPT code 99214 and not 99215.

CPT Code 99223

Covering initial hospital care on a per day basis for the evaluation and management of a patient, this code requires these three components to be fulfilled.

1. Comprehensive history
2. Comprehensive exam
3. Medical decision making of high complexity

52% of services were coded incorrectly out of the total claims submitted between 07-01-2012 and 06-30-2013.  Given below some examples of CERT errors for CPT code 99223:

Although the billing is for CPT 99223, the submitted documentation supports CPT 99221 – which requires detailed/comprehensive history, detailed/comprehensive examination and straight forward / low complexity medical decision making. However, notes submitted documents detailed history and examination and high complexity medical decision making.

With detailed history, expanded problem focused exam and moderate complexity decision making, documentation supports CPT code 99232, which relates to subsequent visit.

Supporting a face to face encounter on the date of service, with no documentation to support the lowest level code for this E/M category; the code will be 99499 and will receive payment for 50% of the billed service.

CPT Code 99222

This code covers initial hospital care on a per day basis for the evaluation and management of a patient, and requires these three components to be fulfilled.

1. Comprehensive history
2. Comprehensive exam
3. Medical decision making of moderate complexity

Data from total claims submitted between 07-01-2012 and 06-30-2013 show 44% of services were coded incorrectly.  Given below some examples of CERT errors for CPT code 99222:

With comprehensive history, detailed exam and moderate decision making, the documentation submitted supports code 99221 and not 99222.

Detailed history, problem focused exam and moderate complexity medical decision making as per 1995 E/M guidelines support CPT code 99232 (subsequent visit). According to Medicare regulations, “in situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes could potentially meet requirements to be reported for an E/M service.”

Why Us?

MedConverge provides E/M Chart Management Audits for your billing and documentation processes which will help reduce your medical coding errors.  For more information on our services with your billing and coding issues, contact us at info@medconverge.com or call us on (800) 811-2103 x11.