American College of Physicians: Internal Medicine — Doctors for Adults ®


Medicare auditors focusing on medical necessity

From the June 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Deborah Gesensway

PHILADELPHIA—After seeing a hypertensive patient for a follow-up visit, you select the appropriate evaluation and management (E/M) code and provide a detailed note documenting the visit. You've met Medicare's documentation requirements, so you don't have to worry about an audit, right?

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Not necessarily. At an Annual Session presentation on E/M guidelines, "E&M Guidelines: Proper Coding in the Office-Based Practice," experts said that if a service is medically unnecessary, no amount of documentation or E/M codes will persuade Medicare to pay you for the visit. As HCFA steps up its efforts to weed out unnecessary services, physicians can expect medical necessity to become a growing issue.

"It doesn't matter if you can generate a nice big note," explained Glenn D. Littenberg, FACP, a Pasadena, Calif.-based gastroenterologist who represents the College on the AMA's Current Procedural Terminology editorial panel. "If it's not medically necessary, it's going to be looked at."

This year, for example, Medicare carriers are expected to scrutinize physicians who repeatedly use the same codes for the same patients, particularly if those codes are for level four or five services, said Arthur N. Lurvey, FACP, medical director for Transamerica, the Medicare carrier in Southern California.

If, for example, you see a hypertensive patient for the fifth follow-up visit in a few weeks and neither the patient's condition nor treatment has changed, you can expect your Medicare carrier to start asking questions. By using E/M codes that indicate that the patient's condition has not changed at all, Dr. Lurvey said, physicians raise questions about whether services are medically necessary. "The exam must be appropriate and the intervals must be appropriate," he said. "Codes must be reasonable and necessary."

In addition to medical necessity, Drs. Lurvey and Littenberg said that Medicare carriers are expected to focus their review and audits on the following problem areas:

  • Critical care codes used to bill for services in the hospital. Because Medicare suspects doctors of overusing high-paying critical care codes, Dr. Lurvey said, these codes will be subject to special scrutiny. HCFA recently sent a detailed memo on the topic to its carriers. Dr. Littenberg said that physicians who use these codes should get a copy of that directive from their local carrier.

  • Level one visits. Although most auditors focus on level four and level five codes, there is growing concern that some physicians may be abusing lower level codes. Dr. Littenberg said that some physicians have billed Medicare for a level one visit as well as shot administration when patients have come in for flu shots, even if no other service was provided. For advice on what's appropriate, he suggested that physicians who frequently use level one codes talk to their local carrier.

  • Unusual coding patterns. Physicians with atypical patient populations for their specialty and physicians who see patients unusually frequently for atypical levels of services and use unusual codes often draw the attention of auditors. Dr. Littenberg recommends that groups focus their own in-house reviews and compliance programs on colleagues who may differ from the norm. Proactively reviewing these physicians' coding patterns, he said, can help ward off future run-ins with Medicare. (See "A look at internists' coding patterns," this page.)

Dr. Littenberg said the following physicians are more likely to be audited and should therefore make sure that documentation strongly supports their coding: physicians who tend to perform many level four and five visits; physicians who provide complex care; and physicians whose patient population will draw attention during a computerized review.

  • Ignored requests for documentation. Too many physicians still throw away letters from carriers requesting documentation, which usually only leads to more attention from auditors.

Besides hurting yourself, Dr. Littenberg said, this behavior affects all physicians. He explained that when the Office of Inspector General announces each year that Medicare spent billions of dollars on improper billings, that figure includes instances in which physicians did not send requested documentation. "We are portrayed in the press as committing great levels of fraud and abuse," he said, "but it's often because people didn't send in their chart notes when they were requested."

Finally, panel members emphasized that while Medicare is planning to increase its scrutiny of physician coding in some areas, HCFA is not out to get internists. Dr. Littenberg said that there is very little random auditing going on, and he explained that only physicians involved in the most egregious cases are being fined or taken to court. Dr. Lurvey added that when Medicare carriers disagree with a frequency or level of service claimed by a physician, they may deny payment or request repayment, but they will not view it as fraud.

Deborah Gesensway is a freelance writer in Abington, Pa.

A look at internists' coding patterns

CPT code Percentage
99211 5%


99213 52%
99214 21%
99215 4%

When Medicare carriers go hunting for billing and coding problems, one of the first things they look for is physicians with atypical billing patterns.

Glenn D. Littenberg, FACP, a Pasadena, Calif.-based gastroenterologist who is the College's representative to the AMA's Current Procedural Terminology editorial panel, suggests that practices compare the codes they bill to those of their colleagues. He said the information above, which is based on 1998 HCFA data, shows how general internists bill Medicare for evaluation and management services.

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