The Miserable Tale of an E&M Code

The Miserable Tale of an E&M Code

The horror story of 99214.

99214. Is that Jean Valjean’s number? No. It is an evaluation and management (E&M) code of moderate complexity.

Few CPT® codes cause goosebumps, a chill in the air, and a pit in your stomach besides 99214. As I said, it is an E&M code of moderate complexity. For a low-complexity visit, the code decreases to 99213. Even lower is a 99212, which is considered a straightforward visit. The code goes as high as a 99215, which denotes high complexity.

Generally, physicians are good at spotting the 99215s and 99212s; the lowest and highest complexities seem simple to spot. However, the middle-complexity codes are a bit subjective. Auditors frequently find 99214s that the auditor thinks should have been 99213s. I am talking about the Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Targeted Probe-and-Educate auditors (TPEs), Unified Program Integrity Contractors (UPICs), and other contractors paid with our tax dollars on behalf of the Centers for Medicare & Medicaid Services (CMS).

I recently came across a Blue Cross Blue Shield (BCBS) audit that found that an urgent care center had a 97-percent error rate. Out of 30 claims, only one claim was considered 99214; 29 claims should have been down-coded to a 99213, according to BCBS. Well, my urgent care center disagreed, and hired an independent auditor to review the same claims that were audited. The independent audit resulted in vastly different results. According to the independent audit, only four of the 30 claims should have been down-coded to 99213.

One should ask, how could two separate auditors audit the same documents and arrive at such disparate results? One reason is that the difference between 99213 and 99214 is subjective. However, subjectiveness was not the only reason for the disagreement.

You see, before 2021, facilities had the choice to follow either the 1995 guidelines or the 1997 guidelines for these CPT codes. And there is a difference between the two guidelines. Instead of choosing either the 1995 or 1997 guidelines, BCBS applied both guidelines, which falsely created more stringent criteria for 99214.

The urgent care center had been verbose about the fact that they use the 1995 guidelines, not the 1997 guidelines. When the independent contractor audited the records, it used the 1995 guidelines only.

All in all, for an accusation of owing $180,000 it cost the urgent care center almost $100,000 to defend itself against what was obviously a faulty audit. So, I’m thinking, why in the world is there insurance for physicians for making a mistake in surgery – medical malpractice – but no insurance for False Claims Act allegations? I mean, medical malpractice allegations mean that there is a victim. But you can be accused of false claims unexpectantly, and your practice can be changed forever.

Recently, I learned of an insurance company that insures doctors and facilities if they are accused of billing Medicare or Medicaid for false claims. Unlike medical malpractice, an accusation of false claims does not yield a victim (unless you see our tax dollars as people); however, an accusation of billing a false claim can cost a doctor, facility, or hospital hundreds of thousands of dollars. Knowing that all things are relative, that is still pennies on the dollar of the penalties under the False Claims Act (FCA).

The company’s name is Curi. Personally, I had never heard of this company. I Googled it after I was placed on a panel. This is an insurance company that pays for attorneys’ fees if you are accused of false claims or an overpayment.

Personally, I think every reader should procure this insurance directly. After 23 years of litigating, I have realized that the worst part about defending yourself against accusations that you owe the government money is the huge price tag associated with it.

Programming note: Listen to healthcare attorney Knicole Emanuel’s live RAC Report every Monday on Monitor Mondays with Chuck Buck.

Facebook
Twitter
LinkedIn
Email
Print

Knicole C. Emanuel Esq.

For more than 20 years, Knicole has maintained a health care litigation practice, concentrating on Medicare and Medicaid litigation, health care regulatory compliance, administrative law and regulatory law. Knicole has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards. She has successfully obtained federal injunctions in numerous states, which allowed health care providers to remain in business despite the state or federal laws allegations of health care fraud, abhorrent billings, and data mining. Across the country, Knicole frequently lectures on health care law, the impact of the Affordable Care Act and regulatory compliance for providers, including physicians, home health and hospice, dentists, chiropractors, hospitals and durable medical equipment providers. Knicole is partner at Nelson Mullins and a member of the RACmonitor editorial board and a popular panelist on Monitor Monday.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering Good Faith Estimates Under the No Surprises Act: Compliance and Best Practices

Mastering Good Faith Estimates Under the No Surprises Act: Compliance and Best Practices

The No Surprises Act (NSA) presents a challenge for hospitals and providers who must provide Good Faith Estimates (GFEs) for all schedulable services for self-pay and uninsured patients. Compliance is necessary, but few hospitals have been able to fully comply with the requirements despite being a year into the NSA. This webcast provides an overview of the NSA/GFE policy, its impact, and a step-by-step process to adhere to the requirements and avoid non-compliance penalties.

Mastering E&M Guidelines: Empowering Providers for Accurate Service Documentation and Scenario Understanding in 2023

Mastering E&M Guidelines: Empowering Providers for Accurate Service Documentation and Scenario Understanding in 2023

This expert-guided webcast will showcase tips for providers to ensure appropriate capture of the work performed for a visit. Comprehensive examples will be given that demonstrate documentation gaps and how to educate providers on the documentation necessary to appropriately assign a level of service. You will gain clarification on answers regarding emergency department and urgent care coding circumstances as well as a review of how/when it is appropriate to code for E&M in radiology and more.

June 21, 2023
Breaking Down the Proposed IPPS Rule for FY 2024: Top Impacts You Need to Know

Breaking Down the Proposed IPPS Rule for FY 2024: Top Impacts You Need to Know

Set yourself up for financial and compliance success with expert guidance that breaks down the impactful changes including MS-DRG methodology, surgical hierarchy updates, and many new technology add-on payments (NTAPs). Identify areas of potential challenge ahead of time and master solutions for all 2024 Proposed IPPS changes.

May 24, 2023

Trending News