While supplies last! Free 2022 Coding Essentials for Infusion & Injection Therapy Services book with every RACmonitor webcast order. No code required. Order now >

For Medicare beneficiaries the former consultations must now be reported using CPT codes for office/outpatient visits (99201 – 99215) as well as hospital inpatient services (99221 – 99233).  This change drastically increases the traditional E/M services’ value, enhances the codes’ impact on provider revenue and, in a paradoxical twist, it makes these services more of a federal and state target following the Centers for Medicare & Medicaid Services (CMS) move to plump up reimbursements for these services (to account for the loss of consultation fees).  Since billions of dollars are paid out to providers each year for E/M services, in particular 99213 and 99214 (the two most frequently reported E/M services), federal and state auditors are watching closer than ever to ensure fewer incidences of improper payments.


Other robust federal audit programs assail providers through a variety of initiatives.  The major audit schema includes, among others, efforts by CMS via jurisdictional Medicare Administrative Carriers (MACs), the Comprehensive Error Rate Testing (CERT) program, the Annual Work Plan by the Office of the Inspector General (OIG) and the aggressive audit program of the Recovery Audit Contractors (RACs).


The following is a “Top 10” accounting of recent federal audit findings within the typical E/M service code ranges for office and inpatient hospital services. For each Top 10 audit result, “survival tips” are also provided:


1.     Illegible, unauthenticated and/or indeterminate authorship of Medical Records (MRs): Illegible physician and NPP signatures, unauthenticated MR notes (i.e., unsigned either by hand or by e-signature), and/or the federal reviewer’s inability to differentiate ancillary staff notes from treating provider’s notes accounts for the preponderance of audit findings.  Survival Tips: Legible signatures are required to certify services; illegible signatures submitted without evidence of proof-of-signature are adjudged by Reviewers as “indeterminate” and equated to unsigned MR documentation.  Likewise, mixing ancillary staff/scribe notes in the body of the clinical note without signature clarification is tantamount to unauthenticated records.  These various documentation errors are denied because “services were unable to be verified as being rendered by the billing provider.”  Ensure the providers and ancillary staff sign/date all clinical note contributions so authorship of MR documentation is clear.  Excluding certain hospice documentation, facsimile stamped signatures are no longer valid for federal purposes.


2.     Non-response to ADRs: Ignoring or not responding in a timely manner to official MR documentation requests, termed Additional Documentation Requests (ADRs) when issued by MACs/Part B Carriers, is another prevalent audit finding.  ADRs are simple MR documentation inquiries to assess and verify services billed.  The request encompasses all documentation germane to the date-of-service (DOS) under investigation; all relevant documentation must be copied and sent to the requesting entity.  Survival Tips: Compliance staff should ensure the logging of each ADR, the processing of which must be tracked and monitored, and final fulfillment confirmed by certified mail.  For larger group practices or multi-location practices, setting up an internal “ADR Response Team” is often an effective way to handle these third party requests for MR documentation.  Follow up and/or remedial steps must be performed once feedback from the requesting entity is received, e.g., analysis of audit results, fiscal impact of repayment demands, provider education in documentation, additional coder training, etc.


3.     Review of Systems (ROS) is missing or poorly documented: Recording the patient’s history is, by audit, the weakest area of provider documentation for office and hospital visits.  Easily the most overlooked element of the history portion of the note is the ROS which, when missing or poorly documented, severely limits the level of the E/M service that can be legitimately reported.  This is paradoxical as the ROS can be expertly obtained by ancillary staff.  Examples of poorly documented ROS include those with blanket statements like “all systems unremarkable” which many MACs/Part B Carriers do not recognize as legitimate.  Survival Tips: There are few reasons why the ROS cannot be thoroughly obtained, unless it is not medically necessary.  If the ROS is obtained on a separate form or questionnaire, the form should be signed/dated by the provider to certify the ROS document is germane to the current visit.  All such segregated data should be bridged to the date-of-service in question, and included in the Reviewer’s package when MR documentation is requested.


4.     E/M code 99211 reported without sufficient documentation: CPT code 99211 is designed for minimal problems requiring quick visits carried out by ancillary staff and supervised by the reporting provider.  Adequately substantiated in the MR documentation 99211 can be reported for myriad services.  Errors in reporting 99211 range from inadequate or no MR documentation to the automatic billing of 99211 with other minor staff services, e.g.,  Bp checks, PPD readings, specimen collection, etc., without cognitive services being performed.  Survival Tips: CPT code 99211 represents a true E/M service; as such, the MR documentation must convey features of both evaluation and management services, i.e., (a) essential clinical information is provided or exchanged based on the patient’s condition or problem and (b) therapy, management or a treatment plan is rendered/provided.  Both actions must be documented.  Since this E/M service is typically furnished by ancillary staff under the provider’s direct supervision, it is reported as “incident to.”  All criteria for incident-to services must be satisfied.


5.     Time used as key component for E/M services but is inadequately documented: Providers can report non-time based E/M services using ‘time’ as the key factor instead of the 3-key components of history, physical exam (PE) and medical decision making (MDM) when counseling and/or coordination of care (CoC) constitute 50% or greater of the total face-to-face time.  Federal auditors find numerous instances of missing or poorly documented time(s) when the provider clearly intended to use time as the singular key component for the E/M service reported.  Survival Tips: Document two strata of ‘time’ when relying on time as the leveraging factor: (1) total face-to-face time for the entire encounter and (2) total time spent in counseling and/or CoC.  The second stratum demonstrates the >50% rule; the first stratum creates the frame of reference for stratum #2.  For office services non face-to-face time (i.e., time expended in pre-/post-visit work) cannot be included in the total time calculated; inpatient services, however, can include non face-to-face unit/floor time spent in the care of the patient.  Content of counseling/CoC must be fully documented.


6.     Misapplication of modifier -25: Modifier -25 is reported with an E/M code when significant, separately identifiable E/M services are rendered by the same physician on the same day of a procedure or other service.   Federal auditors have found three frequently occurring errors after reviewing the MR documentation:  (1) modifier -25 was incorrectly reported on a non-E/M service, e.g., 93000-25 for EKG; (2) modifier -25 was reported with an E/M code when the patient presented solely for a minor procedure, e.g., joint injection, however, the E/M service was not documented or was not medically necessary; and, (3) modifier -25 was not reported but was needed when an E/M service and a minor procedure (with a global surgery indicator of “000”) were provided.    Survival Tips: Modifier -25 is designed to allow certain E/M services to bypass system edits.  It should only be appended to an E/M service to make clear that particular service is “significant, separately identifiable” and therefore separately payable.  MR documentation must substantiate these separately payable circumstances.  The triple-zero global surgery indicator (“000”) signifies that only the day of the procedure is included in the global surgery period.  If the E/M service is not reported with modifier -25 in these circumstances the service is denied.


7.     The “4×4 Rule” and the conundrum of expanded problem focused (EPF) vs. detailed physical exams: Confusion surrounds these two specific exam levels because the 1995 and 1997 E/M Documentation Guidelines (DGs) are ambiguous for both EPF and detailed exams by stating both must contain “2-7 elements,” specifying the EPF level requires a “limited” exam and detailed requires an “extended” exam.  Both must address “the affected areas/systems and any other symptomatic or related areas/systems, up to 7.”  The similar definitions for “limited” and “extended” have caused provider misinterpretation and allowed for a predominant auditor finding of “insufficient PE documentation for a detailed level exam” such as for E/M codes 99203, 99214, 99221 and 99233.  Survival Tips: Know the “4×4 rule;” it comprises four elements or items examined within four body areas or organ systems.  For providers, the “4×4 rule” is a quick and uncomplicated method to avoid misinterpretation of these similar MR documentation levels.  Compliance personnel should check with the Part B Carrier to ascertain applicability.  Of note, federal auditors are tasked with referencing both sets of E/M DGs – 1995 and 1997 – adjudging each case being reviewed so the final assessment best benefits the provider.


8.     Rules for reporting CPT code 99499 Unlisted E/M Service: CMS addresses billing of CPT code 99499 (MCPM 100-04, Chapter 12, §30), stating “the Carrier has the discretion to value the service.”  In effect, the Part B Carrier is in control and many maintain that 99499 should be reported only in rare instances.  “Rare” is the operative term and used repeatedly in official literature.  Adjudicators must review associated documentation and apply individual consideration (IC) protocols for appropriate pricing of each service reported under 99499.  Survival Tips: Report 99499 in rare circumstances and only per Carrier instructions.  A “rare” example provided by a local MAC follows: “If documentation criteria for initial inpatient hospital services 99221-99223 cannot be met and if … even a 99221 cannot be met, but the documentation does meet the criteria for subsequent inpatient hospital services 99231-99233, then code appropriately even though it is chronologically an admission.  If the documentation does not even meet the criteria for a 99231, then code 99499.”


9.     Modifier -24 and the global surgical period: When reporting E/M services after a major procedure but during a global surgical period (within 90 days) of a major procedure or after a minor procedure but also during the procedure’s global surgical period (up to 10 days), the appropriate documentation must support the service and the E/M code must be appended with modifier -24 to circumvent system edits.  Documentation must detail why an E/M service should be paid within the global surgical period.  According to the MCPM 100-04, Chapter 12, §40.2.A.7, “services submitted with modifier -24 must be sufficiently documented to establish that the visit was unrelated to the surgery.  An ICD-9-CM code that clearly indicates the reason for the encounter was unrelated to the surgery is acceptable documentation.”  Survival Tips: This is one of the few E/M services included in the 2010-2012 OIG Annual Work Plans.  Implement steps to prevent inadvertent reporting of post-op E/M services as separately payable when the patient is in a post-surgical status, and bill these services correctly when appropriate.


10.   Missing or poorly documented key components of the E/M service: This “Top 10” mention is the last-listed but in aggregate it is the most prevalent of all audit findings.  For most E/M services 3-key components govern code selection: (1) History, (2) PE and (3) MDM.  For new office visits and initial hospital inpatient services these key components must be included in the documentation.  When only 2-key components are required to be documented, i.e., for subsequent office or hospital visits, at least two of the three components must meet the service’s lowest threshold requirements.  “Survival Tips” are interspersed with federal audit findings as follows:


(a) History:  Missing or lack of recorded critical elements including chief complaint (CC), past medical, family/social history (PFSH), and history of present illness (HPI). [ROS problems were previously addressed]  Contradictory data between elements is a common error, e.g., the CC states one reason for the visit but the HPI details a different problem.  Some Carriers require the CC and HPI to be documented only by the treating provider.  Terms like “noncontributory” under the PFSH or ROS may be invalid; internal compliance staff must know Part B Carrier jurisdictional preferences.


(b) PE:  Missing or insufficient documented information. A common provider PE statement is “no change from prior visit.”  When 3-key components are required for the E/M service, this brief statement is inadequate and will be discounted by federal Reviewers.  “Negative” and “WNL” notations are acceptable forms of documentation for unaffected areas/organ systems but are unacceptable under E/M leveling criteria for affected areas/organ systems that relate to the CC and/or HPI within the History.


(c) MDM:  Truncated or disorganized data.  MDM information conveys the complexity and risk of the service, and must be fully documented.  Additionally, disorganized MDM data can cause mistakes in copying and assembling audit packages for Reviewers.  This is easily remedied when the provider creates a data bridge between the body of the visit text and other related supporting documents so that all elements of each date-of-service is connected.  The data bridge is especially critical when the provider has reviewed old MRs, ordered tests/studies, carried forward or revised diagnoses and medications, etc.  This also relates to History elements, e.g., the ROS, when recorded and maintained on separate forms.  Educate staff tasked with processing MR and ADR requests on the proper assembling of complete audit packages for federal Reviewers.


Meticulous MR documentation has always been one of the keystones of quality patient care.  It is certainly the much-touted foundation for a successful transition from ICD-9-CM to ICD-10-CM/PCS code system implementation (still at this writing, by Oct. 1, 2013).  It also has the capacity to protect providers in myriad scenarios including federal audits.  The disparate audit findings included in this article are not all-inclusive but are among the predominant audit findings that have surfaced during federal review processes.  Adhering to the survival tips can help physician practices avoid federal recompense demands by preventing E/M services from being downcoded or denied.


About the Author


Michael Calahan, PA, MBA, CCS, CCS-P, CPC, CPC-H, AHIMA Certified ICD-10-CM/PCS Trainer, is the Director of Physician Services at KForce Healthcare, Inc., working in compliance, coding and revenue cycle management in the physician and facility arenas.


Contact the Author


mcalahan@kforce.com or mikiecal@hotmail.com


To comment on this article please go to editor@racmonitor.com




  1. Medicare Claims Processing Manual/Internet-Only Manuals 100-04, Chapter 12 Physicians/Nonphysician Practitioners, Sections 30 and 40 (various citations as disclosed): Consultations, CPT Code 99499, Modifiers -24 and -25 et al
  2. Medicare Program Integrity Manual/Internet-Only Manuals 100-08, Chapter 3 Verifying Potential Errors and Taking Corrective Actions, Section Facsimile Signature Requirements
  3. CMS Transmittal 327/Change Request 6698 June 16, 2010 (Revised), Signature Guidelines for Medical Review Purposes
  4. Evaluation and Management Documentation Guidelines, 1995 and 1997, as published by two oversight entities: CMS www.cms.gov and AMA www.ama-assn.org
  5. CERT errors (2009 – 2012) specific to E/M services; E/M audit FAQs; compounded information best viewed at three Medicare Carrier web sites:  (a) Wisconsin Physician Services (WPS) Medicare, (b) Trailblazers Medicare, and (c) Cahaba Medicare (MAC A/B J10)
  6. CMS Transmittal 1875/Change Request 6740, December 14, 2009, Revisions to Consultation Services Payment Policy
  7. Trailblazer Health Interprises, LLC, Evaluation and Management Services (training manual), September 2011
  8. Highmark Medicare Services, E/M FAQs “13. What is the 4x4method for determining if an examination is scored as an expanded problem focused or detailed?”  Posted 10-5-2009; revised 8-29-2011
  9. U.S. Department of Health & Human Services, Office of the Inspector General (OIG), Office of Evaluation & Inspections Reports, Review of Incident To Services, Report 09-06-00430, August 2009

U.S. Department of Health & Human Services, OIG Reports, 2012 Annual Work Plan, accessed October 2011


RACs Obtain CMS Approval for First Home Health Issue and Begin Testing for Additional Issues



You May Also Like

Leave a Reply

Your Name(Required)
Your Email(Required)