Published 9/1/2013
Mary LeGrand, RN, MA, CCS-P, CPC

Is Your E&M Documentation an Audit Risk?

Conduct an internal evaluation and take action

The Work Plan for the Centers for Medicare & Medicaid Services’ Office of the Inspector General (OIG) regularly targets potentially inappropriate evaluation and management (E&M) service payments. This year, OIG has focused on disproportionately high frequency utilization of the same level of E&M service by the same provider.

The impetus for this close scrutiny is that Medicare contractors noticed an increased frequency of medical records with identical documentation across services. They also noted a shift to a higher proportion of claims with codes 99214 (office visit, established patient, level 4) and 99215 (office visit, established patient, level 5). Coincidentally, these trends coincided with the nationwide increase in the use of electronic health records (EHR).

Although this “EHR fallout” is the latest reason for the OIG’s focus on E&M coding, it won’t be the last. Whether you use an EHR or not, it’s good practice to review your E&M coding patterns and documentation on an annual basis. You’ll gain awareness of your own level of coding, understand how it compares with your peers’, and determine whether your documentation will support the level of codes billed in the event of a third-party audit.

The following steps will take you through an internal audit of your E&M coding patterns.

1. Revisit the basic documentation rule.
Medicare requires a unique note for each patient encounter and an E&M code selected on the basis of the patient history, physical exam, and medical decision making for that specific encounter. The documentation should support the level of service reported. Although time and counseling may occasionally be contributing components, the history, physical, and medical decision making are typically the determining factors.

This may sound like “E&M 101,” but it’s worth the reminder if you use an EHR. Certain EHR features make it easy to ‘pull forward’ (cut-and-paste) documentation from previous visits, putting the onus on you to ensure that the unique elements of each specific encounter are documented. If the documentation is the same as the previous visit, Medicare considers the note a clone and the note won’t pass the documentation rule in an audit. (See “EHR: E&M Code Friend or Foe?” below).

2. Generate a CPT frequency report.
This standard practice management system report shows how many times each billing provider uses each CPT code. At least annually, you should generate one full year of data for each individual physician and for the practice in total.

3. Benchmark your coding patterns.
This analysis is fast and easy to do if you use the AAOS CodeX product. The “E&M Analyzer” feature of CodeX compares your E&M coding patterns against state and national data, using the most recently published CMS claims database. Just enter your CPT frequency from the report generated in step 2, and the Analyzer generates colored-line graphs comparing your usage with other orthopaedists in your state and nationally (
Fig. 1).

If you do not use CodeX, you can obtain orthopaedic CPT data directly from CMS for a small fee, but you will need to parse and load the data into formulas or spreadsheets on your own.

If your individual usage pattern generally follows that of your colleagues as well as state and national norms, you are not an outlier, and your risk of inviting a CMS audit due to usage patterns is less likely. (If your group includes subspecialists such as joint and spine surgeons, their patterns may differ from the rest of the group.)

But if your or a partner’s data fall outside state and national norms, you may be targeted for an audit. This should spur you to conduct an internal or external chart review. If more than one physician in your practice is an outlier, consider engaging the services of a healthcare attorney before you proceed with documentation review. Doing so allows the practice to invoke attorney-client privilege with the findings, and the attorney can assist with evaluating the level of risk to the practice and can support the group with more informed recommendations.

4. Audit 10 charts per physician.
Conduct your own internal audit by checking the documentation on 10 charts for each physician in the practice. Pull each chart randomly, selecting different dates of E&M service. Look up the code that was billed in the computer. Review the chart note to determine whether it supports the billed code.

If you have an EHR, pay particular attention to whether the notes look unique or cloned. Ask yourself whether they would be helpful or maddening to a referring physician. Many EHRs generate multiple pages of the same rote text, making it difficult to identify your findings. Also, do the notes look virtually identical for the same level of service? If so, you or your colleagues must improve documentation of unique visit elements.

This process is more collaborative if your group gets together to review each other’s notes and discuss findings. If you’ve engaged an attorney, invite him or her to participate. Some practices have considered spot prepayment audits to ensure the documentation supports the level of E&M service being reported.

5. Schedule E&M training, if needed.
If the results of the previous action steps indicate that coding levels aren’t being selected properly or documentation is not compliant, schedule your team for E&M education.

6. Document everything in your compliance plan.
Log the internal evaluation process, results, and actions. If you’ve engaged a healthcare attorney in the process, work with him or her on how to specifically document the activity.

If you don’t have a compliance plan, you need to develop one, posthaste. In an audit, this risk management and reduction tool is an essential piece of evidence that the practice is making an effort to code, document, and bill correctly.

Make it a practice goal to complete an internal audit by the end of 2013. If you lack the time or internal staff capable of undertaking the project, engage the assistance of a reputable third party. Choose a vendor with good credentials and deep experience in orthopaedics. And don’t forget to check references.

Mary LeGrand, RN, MA, CCS-P, CPC, is a nationally recognized coding and reimbursement expert who has been an instructor for AAOS for more than 12 years. This article has been reviewed by the AAOS Coding, Coverage, and Reimbursement Committee.

EHR: E&M Code Friend or Foe?
EHRs have many merits. But improper use of certain features can increase audit risk. In particular, use caution with the following three features:

1. Visit templates
Customizing individual visit templates is a critical step toward good documentation. Each surgeon should have individualized templates for the top 10 or 15 conditions or injuries seen, such as arthritic knee, hip consultation, or hammer toe. Without customization, the vendor’s standard template will create multipage notes that don’t necessarily document what was done.

2. ‘Pull it forward’ notes
Generally, EHRs automatically ‘pull forward’ the History of Present Illness (HPI) documentation from each previous patient encounter. This automation is great, but you must review and update the HPI each time or you’ll create a series of cloned notes that won’t stand as unique encounter documentation. Cloned notes are also annoyingly verbose and don’t easily call out pertinent positives. Remember, the billing provider or physician must obtain the HPI at each visit.

3. Coding calculators
Medicare says it now adjudicates a greater percentage of 99214 and 99215 codes in almost all specialties. It’s likely that Medicare may target these code levels for an audit sooner rather than later. Be sure that if you bill for these codes, your documentation justifies the encounter. Avoid using coding calculators to add information to the chart note for the purpose of reporting a higher level of service.