Evaluation and Management Codes

E/M services are the most common CERT errors found with Medicare Part B claims. The medical records that were provided either do not support the level of service billed or do not indicate the service was performed. The E/M service is either denied or adjusted to a lower level of service code.

In some situations the billing provider relies on a third party to submit the medical records for certain services (e.g., hospital visits, lab results, physician orders). The CDC either receives incomplete or no medical records, which results in a claim denial or adjustment to match the documentation that was received. The billing provider is solely responsible for submitting all the medical records to the CDC, when a claim has been selected by CERT. All medical records need the CERT barcode as a cover sheet.

Avoid an E/M claim from being denied or adjusted by:

• having an internal audit process for E/M codes;
• being familiar with E/M guidelines and coding the service with the correct level of care:
  • 1995 Documentation Guidelines for Evaluation & Management Services
  • 1997 Documentation Guidelines for Evaluation & Management Services
• verifying the code selected matches the documentation provided by the physician or nonphysician practitioner;
• submitting all medical records to support each service billed on the claim; all medical records need the CERT barcode as a cover sheet;
• knowing the seven components used to define the levels of E/M services as defined in the E/M guidelines; these components are:
  • history
  • examination
  • medical decision making
  • counseling
  • coordination of care
  • nature of presenting problem, and
  • time
• verifying all medical records are being submitted to the CDC if a third party is involved (e.g., hospital, laboratory, doctor’s office); the billing provider is solely responsible for submitting all the medical records to the CDC when a claim has been selected by CERT.

E/M errors can also be avoided if the billing providers do not:

• bill a higher level when a lower level of service is warranted; the volume of documentation should not be the primary factor upon which a specific level of service is billed;
• bill a higher level of service when only one component is exceeded; all components must be met or exceeded to use a higher level of service code;
• bill the same level of subsequent hospital visit codes without reviewing the medical records; the components must be met or exceeded, for each visit, to use the same level of care code.

Reviewed 11/14/2024