Upcoding of office visits – reported trends spark CMS audit

Two new reports from the Office of the Inspector General (OIG) and The Center for Public Integrity show that billing trends over the past 10 years reflect a steady increase in billing Medicare for higher paying services. This trend was shown to be particularly prevalent in the billing of established patient office visit codes. 

Summary of Reports

  • In May, the Office of the Inspector General (OIG) published a report on Coding Trends of Medicare Evaluation and Management Services. The OIG study was conducted to determine patterns behind the 48 percent increase in billing of evaluation and management (E/M) services between 2001 and 2010. The study results reflect that in general, physicians “increased their billing of higher level E/M codes in all types of E/M services.” Specifically, the study “identified approximately 1,700 who consistently billed higher level E/M codes in 2010.” The OIG encouraged a review of physicians billing higher level E/M codes.
  • A similar independent report conducted by The Center for Public Integrity was published this week and received media coverage in the Washington Post. Similar to the OIG, the Center for Public Integrity reviewed E/M services billed to Medicare between 2001 and 2010. The report quantifies the upcoding as resulting in $11B in additional costs to the Medicare system. The Center for Public Integrity presents possible explanations for the upcoding including fraud and abuse as well as the need for physicians to compensate for rising medical office expenses. 

Coinciding with the publication of these reports, the Centers for Medicare & Medicaid Services (CMS) approved a claims audit for the highest level established patient office visit (code 99215). A timetable for the audit and information about the effected providers has not yet been announced. The AASM will continue to monitor coverage of these studies as well as the proposed CMS audit and provide members with updates.

2012-09-18T00:00:00+00:00 September 18th, 2012|Clinical Resources|