Purpose:

This bulletin is written as an educational tool to discuss the specific findings of the evaluation and management (E&M) service wide probe initiated on February 27, 2006. The notice is also intended to decrease the paid claims error rate, and to avoid provider denials.

Background:

Through data analysis, a high error rate was found for evaluation and management (E&M) billing.

Review Findings:

A random service wide probe of evaluation and management (E&M) was completed September, 2006.  The calculated error rate for this probe was 24%. The results of the Probe are listed below:

The majority of denials were related to insufficient documentation. The following is a summary of denial information:

• Documentation did not support a separate & identifiable evaluation and management.
• Documentation did not support a face to face encounter. 
• Documentation submitted did not support services provided on date billed. 
• Documentation submitted did not support medical necessity of other services billed on the claim.

It is very important that providers contact third parties such as physicians or other providers, health care facilities, or suppliers and request a copy of the medical documentation necessary to fully support the services billed to Medicare. It is the responsibility of the provider submitting the claim for payment to obtain all the requested documentation, regardless of where the records are kept.

When a request for Additional Development (ADR) is received, please review and provide the requested documentation prior to submission of claims in order to ensure appropriate review of all information supporting medical necessity for the services billed. Documentation requested on the ADR is as follows:

Providers should send the following information:

1. Clinic/treatment room/emergency room records
2. Clinical documentation of diagnosis or symptoms to justify services.
3. History of past and present illness, physical exam, progress notes.
4. Results of all testing/services billed.
5. Itemized bill.
6. Above documentation should be provided for each E&M billed.        

Due to the significant calculated error rate of 24%, this educational article is being provided. A future medical review probe is planned to assess for improvement in claims for evaluation and management (E&M).   

Provider Feedback Survey

Highmark Medicare Services offers education and training related to Medical Review (MR) priority issues including:

• Issues identified through data analysis
• Provider identified issues
• Medicare programs and policy, and
• Revisions/changes to regulations and guidelines

References

Frequently Asked Questions about Evaluation and Management Codes