Audit your ED E/M criteria

Auditors have been reviewing medical necessity for inpatient services for years and Recovery Auditors (RA) have recouped millions of dollars in overpayments. Now outpatient providers are beginning to see more and more medical necessity audits, especially in the ED and for evaluation and management (E/M) levels.

CMS continues to monitor E/M levels and indicated in the 2013 OPPS Final Rule that level distribution remains fairly normal and relatively stable distribution. CMS also notes a slight shift of Level 4 and 5 visits in relationship to Levels 1, 2, and 3.

“This is something we certainly want to keep our eye on and maybe take a second look at our criteria and the medical necessity for the services that we’re coding and billing,” says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer,president of Edelberg Compliance Associates of Baton Rouge, La. “When you see something in final rules or regulations or any of the transmittals that CMS is sending out, it tells you that CMS is going to be taking a closer look and that could mean audits for all of us.”

Overcoding in the ED is less of a problem than undercoding, Edelberg says.

CMS and RAs are increasingly scrutinizing short inpatient stays and observation services, says Joanne M. Becker, RHIT, CCS, CCSP, CPC, CPC-I, AHIMA approved ICD-10-CM/PCS Trainer. Becker is associate director in the Joint Office for Compliance at the University of Iowa hospitals and clinics in Iowa City.

Because of the increased scrutiny on one-day stays, many facilities are instead placing patients in observation, Becker says. The next logical step for RAs then is to focus on observation. “We even have heard that some RAs are looking at observation visits as to whether or not the patient should have even been there at all,” she says.

Editor’s Note: This article is an excerpt from JustCoding.com.