Recently, there has been increased interest and attention to fraud and abuse in healthcare. The current estimate of $23 billion was recently released by the Health Care Financing Administration (HCFA) as a measure of the scale of this problem. Many efforts, coupled with serious funding, are under way to ferret out examples of such abuse. Inaccurate billing for the appropriate level of Evaluation and Management (E/M) services provided is high on the list. This upsurge in attention to how E/M services are billed was a significant factor in the legal settlements reached by several academic healthcare centers last year.
A project to specify the components for different levels of documentation required for E/M services (office visits, consults, etc.) provided by physicians has been compiled through the efforts of the American Medical Association (AMA) and HCFA. The purpose was to provide the specifications for preparing or reviewing documentation for the E/M services. Another objective was to lay out objective criteria for use in chart and record review that could identify deficiencies that did not match the record to the level of service billed. These new policies specifically state what details must be specified in the patient record to bill for E/M services. There is extensive criteria to follow when billing for detailed or comprehensive examination, especially when confined to a single system such as neurological.
If patient records are reviewed and do not meet these explicit criteria for the level of service billed, the physician could be subjected to stringent penalties. The details of these documentation criteria are available on the Internet at www.hcfa.gov under a heading entitled: Medicare/master1.wp6 or .pdf. A copy will also be posted on NEUROSURGERY://ON-CALL® if you wish to examine the details and download it from that site.