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

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

Compliance as a Revenue Strategy

Compliance as a Revenue Strategy

Grab your pens, alert your billing teams, and cue up your electronic medical record (EMR) vendors, because the Centers for Medicare & Medicaid Services (CMS)

Read More

Leave a Reply

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

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24