FOCUS on E&M DOCUMENTATION

Medical record documentation is the key to determining whether an E&M code accurately represents the care provided and meets the overarching Medicare criterion of medical necessity. To assist GHI Medicare in making appropriate payments for your E&M services, ensure that your documentation adequately supports all components of the level of E&M service reported, e.g., history, examination and plan of management.

CERT and E&M

Recent Medicare Comprehensive Error Rate Testing (CERT) Reports reveal high paid claims error rates for E&M services on reviewed claims. These errors are primarily due to insufficient documentation in the medical record and are the top contributor to CERT errors both nationally and locally. The majority of high-level E&M errors have been identified as “up-coded.” Errors in “under-coding” also contributed to the high E&M error rate.

HOW WE CAN REDUCE THE E&M CERT ERROR RATE

GHI MEDICARE

• E&M coding seminars are posted on www.ghimedicare.com. Send an E-mail request to partbprov@ghimedicare.com.
• Focused prepayment edits identify high-risk claims for medical review and provider education.
• Postpayment medical review is conducted based on unusual trends or aberrancies identified through data analysis.

PROVIDERS

• Consider performing a random sample self-audit of your medical records to determine whether documentation complies with E&M guidelines and Local Coverage Determinations (LCDs).
• Review template tools used for billing to ensure they represent the levels of service you render.
• Meet with billing staff periodically to discuss their coding or billing questions and to see if additional training is needed.
• Request a Comparative Distribution Report (CDR) to see how your practice compares to that of your peer group.

Mail or fax your request to:

GHI Medicare
Program Evaluation
25 Broadway, 12th Fl
New York, NY 10004
Attention: Medical Review
Fax # (646) 458-6763
Please indicate on your request Attention: Medical Review

Register for a scheduled E&M coding seminar as noted above or request a separately scheduled group seminar by sending an e-mail to partbprov@ghimedicare.com.

Through working collaboratively, we can succeed in this important CMS initiative. Please share other ideas you may have by contacting us at partbprov@ghimedicare.com.