(HealthDay News) — Nearly 42% of Medicare claims for evaluation and management (E/M) services are incorrectly coded, according to an article published June 2 in Medical Economics.

The author of the article, Daniel R. Verdon, writes that a U.S. Department of Health and Human Services’ Office of the Inspector General study found that Medicare inappropriately paid approximately $6.7 billion for incorrectly coded claims and those lacking proper documentation in 2010. This represents 21% of Medicare payments for E/M services.

According to Verdon, the study found that incorrect coding included both upcoding and downcoding, while 19% of claims were lacking proper documentation. Among high-coding physicians, claims were more likely to be incorrectly coded or insufficiently documented compared to claims from other physicians. The report recommends that the Centers for Medicare & Medicaid Services (CMS) should: (1) educate physicians on coding and documentation requirements for E/M services; (2) encourage contractors to review E/M services billed for by high-coding physicians; and (3) follow-up on claims for E/M services that were paid in error. However, Verdon notes that in an opinion piece accompanying the report, CMS says the recommendation to encourage contractors to review E/M services billed by high-coding physicians is cost-prohibitive.

“Given the substantial spending on E/M services and the prevalence of error, CMS must use all of the tools at its disposal to more effectively identify and eliminate improper payments associated with E/M services,” the report states, according to the Medical Economics article.

More Information