E&M coding still 2004 OIG target

Healthcare Financial Management, Dec, 2003

Evaluation and management (E&M) coding, billing for consultations, and pricing for physician-prescribed drugs are among the areas of focus for the HHS Office of Inspector General (OIG) in 2004. According to the OIG, the 2004 work plan will include investigating physician coding of E&M services, with a focus on whether adequate controls existed to identify physicians with aberrant coding patterns.

Another area of focus is the use of modifier 25, a code to indicate billing for E&M services on the same day as a procedure or other services. According to the OIG, $1.7 billion of the $23 billion billed for E&M services in 2001 was under modifier 25. Generally, physicians cannot bill for both E&M and a procedure on the same day unless the E&M service is unrelated to the other procedure.

In addition, the OIG will determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative edits (NCCI), Medicare paid $565 million to providers that included the modifier with code pairs within the NCCI, according to the OIG.

To access the 2004 OIG work plan, go to www.oig.hhs.gov/publications/workplan.html.>

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