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Defending an Adverse E/M Audit:

What the Guidelines Really Say

Presented by:

Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CHCC

LEARNING OBJECTIVES

• Identification of areas within the E/M Guidelines that require

subjective analysis leading to disputes regarding E/M Code

Levels.

• Review of common approaches to E/M Analysis that require

use of tools external to the Guidelines and the implications of

this fact when reporting audit results.

• Identification of errors - applying the express provisions of the

guidelines to effectively challenge inappropriate down-coding of

E/M Services.

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WHAT GUIDELINES?

• The most critical step in any audit is to delineate binding from non-binding standards.

• E/M Guidance is contained in a variety of publications:– AMA CPT®

– NCCI General Coding Principles

– CMS Pubs – Medicare Claims Processing Manual, IOM Pub 100-4, Ch. 12, Section 30.6.1.

– Documentation Guidelines for Evaluation and Management Services jointly published by AMA/HCFA (1995)

– Documentation Guidelines for Evaluation and Management Services jointly published by AMA/HCFA (1997)

– Commercial Carrier Medical Policy

– Thousands of other publications

• Which are binding?

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AMA CPT® E/M Guidance• What do the AMA CPT® E/M Guidelines contained within CPT® tell us

relative to scoring E/M Services?– Of the six descriptive components, that History, Examination and Decision-Making

are “key” components.

– It provides five descriptive categories for “Nature of the Presenting Problem” but does not indicate how these, if at all, influence the level of any key component or of the overall level of E/M service.

– Defines the informational elements of past history, social history and the organ systems involved in a review of systems.

– With respect to scoring:

• Determine the Extent of History

• Determine the Extent of Examination

• Determine the Complexity of Medical Decision Making

– Given the instructions provided, how do we do this objectively?

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AMA CPT® E/M Guidelines• Determine the Extent of the History

– Consistent with the Documentation Guidelines published by AMA/HCFA in 1995, AMA

provides descriptions of the various levels of history and nothing more as follows:

• Problem focused: Chief complaint; brief history of present illness or problem.

• Expanded problem focused: Chief complaint; brief history of present illness; problem

pertinent system review.

• Detailed: Chief complaint; extended history of present illness; problem pertinent system

review extended to include a review of a limited number of additional systems; pertinent

past, family, and/or social history directly related to the patient's problems.

• Comprehensive: Chief complaint; extended history of present illness; review of systems

that is directly related to the problem(s) identified in the history of the present illness plus a

review of all additional body systems; complete past, family, and social history.

– How does CPT® define the highlighted terms?

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AMA CPT® E/M Guidelines• Determine the Extent of the Examination

– Consistent with the Documentation Guidelines published by AMA/HCFA in 1995, AMA provides descriptions of the various levels of examination and nothing more as follows:

• Problem focused: A limited examination of the affected body area or organ system.

• Expanded problem focused: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

• Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ system(s).

• Comprehensive: A general multisystem examination or a complete examination of a single organ system. Note: The comprehensive examination performed as part of the preventive medicine E/M service is multisystem, but its extent is based on age and risk factors identified.

– While CPT® does identify the organ systems and body areas for purposes of CPT® , how does CPT® define the highlighted terms?

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AMA CPT® E/M Guidelines• Determine the Complexity of Medical Decision Making

– Consistent with the Documentation Guidelines published by AMA/HCFA in 1995, AMA provides a description of the three decision-making elements and a table for evaluating the level of medical decision-making that includes many undefined terms as follows:

• The number of possible diagnoses and/or the number of management options that must be considered

• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed

• The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options

Four types of medical decision making are recognized: straightforward, low complexity, moderate complexity, and high complexity. To qualify for a given type of decision making, two of the three elements in Table 1 must be met or exceeded.

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AMA CPT® E/M Guidelines• Determine the Complexity of Medical Decision Making

• How does CPT® define the highlighted terms?

Number of Diagnoses

or Management

Options

Amount and/or

Complexity of Data to

be Reviewed

Risk of Complications

and/or Morbidity or

Mortality

Type of Decision

Making

minimal minimal or none minimal straightforward

limited limited low low complexity

multiple moderate moderate moderate complexity

extensive extensive high high complexity

Table 1

Complexity of Medical Decision Making

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AMA CPT® E/M Guidelines• Time as a Factor in the Level of E/M Service

– Consistent with the AMA/HCFA Documentation Guidelines for E/M Services (1995/1997), CPT® also includes the following instruction where counseling/coordination of care dominate the physician’s face-to-face time with the patient performing E/M services:

When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.

Note: the highlighted words represent two key differences between the AMA CPT® Instructions and the 1995/1997 Documentation Guidelines for E/M Services published by AMA/HCFA.

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NCCI General Coding Principles• NCCI defines WHEN an E/M is reportable in addition to a procedure that is classified

with a “000”, “010” or “090” Global Surgical Indicator but does not define or describe HOW to select the type of level of E/M Service.

Since NCCI edits are applied to same day services by the same provider to the same beneficiary, certain Global Surgery Rules are applicable to NCCI. An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances.

If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

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Medicare Claims Processing Manual• The Medicare Claims Processing Manual provides the following

instruction regarding selection of the “Level of Evaluation and Management Service”

– Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. Pub 100-4, Ch. 12, §30.6.1.A

How do we score that?

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Medicare Claims Processing Manual• The Medicare Claims Processing Manual provides the following

instruction regarding selection of the “Level of Evaluation and

Management Service”

– Instruct physicians to select the code for the service based upon the content of the

service. The duration of the visit is an ancillary factor and does not control the level

of the service to be billed unless more than 50 percent of the face-to-face time (for

non-inpatient services) or more than 50 percent of the floor time (for inpatient

services) is spent providing counseling or coordination of care as described in

subsection C. Pub 100-4, Ch. 12, §30.6.1.B

How do we score that?

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Medicare Claims Processing Manual• The Medicare Claims Processing Manual provides the following instruction

regarding selection of the “Level of Evaluation and Management Service”

– Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim. Pub 100-4, Ch. 12, §30.6.1.C

We can score when the documentation supports a time-based E/M, otherwise, how do we score the E/M?

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Medicare Claims Processing Manual• The Medicare Claims Processing Manual provides the following instruction regarding selection of the

“Level of Evaluation and Management Service”

Contractors must advise physicians that to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).

The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.

The comprehensive examination may be a complete single system exam such as cardiac, respiratory, psychiatric, or a complete multi-system examination. Pub 100-4, Ch. 12, §30.6.1.D

What about Decision-Making? Regardless, How Does This Help us to Determine the Level of E/M Service?

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AMA/HCFA E/M Guidelines(95/97)• Which Guidelines to Use?

– 2002 HHS OIG Fraud and Abuse Work Plan

• What Makes Either of these Guidelines Binding?– Medicare?

• Program Integrity Manual instructs that “MACs, CERT, Recovery Auditors, and ZPICs shall determine that an item/service is correctly coded when it meets all the coding guidelines listed in the Current Procedural Terminology-4 (CPT-4), Coding Clinic for ICD-9, Coding Clinic for HCPCS, and any coding requirements listed in CMS manuals or MAC articles” Pub 100-8, Ch. 3, §3.6.2.4

– Federal Health Benefit Programs?– Statutory Reimbursement Programs (Auto/Comp)?– Commercial Payers?

• Even if we accept that these Guidelines are Binding…– Is it possible to objectively score the level of E/M Service based on the text

alone?

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AMA/HCFA E/M Guidelines(95)• History

– 1995 Guidelines not only define the various levels of history, but completely define what must be documented for each history element associated with each level of history. As a result, the level of history can be objectively determined under these guidelines.

• Examination– 1995 Guidelines, similar to CPT® provide only general descriptions of each level of examination

as follows:

• Problem Focused -- a limited examination of the affected body area or organ system.

• Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

• Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

• Comprehensive -- a general multi-system examination or complete examination of a single organ system.

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AMA/HCFA E/M Guidelines(95)• Examination

– 1995 Guidelines, also provide the following documentation guidance instructions

• The extent of examinations performed and documented is dependent upon clinical judgement [sic] and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

– DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient.

– DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described.

– DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

– DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.

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AMA/HCFA E/M Guidelines(95)• Scoring the Examination Using the Express Guidance

– Problem Focused:• Any evidence of analysis of the affected organ system is sufficient for a

problem focused examination.

– Expanded Problem Focused vs. Detailed• Clearly the affected and other symptomatic or related organ systems must be

evaluated.• It is unclear, however, what the difference is between a “limited” and an

“extended” evaluation with respect to the “affected body area or organ system”

– Comprehensive• Based on the documentation guidance, evidence of evaluation of 8 organ

systems is sufficient for a comprehensive exam where a multi-system exam is performed; however, it is unclear what constitutes a “complete” examination of the affected body area or organ system.

As a result, only the problem focused and potentially the comprehensive levels of examination can be determined with certainty.

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AMA/HCFA E/M Guidelines(95)

• Scoring Decision-Making

– Similar to the CPT® guidance, the 1995 Guidelines Provide a General Outline to What is Involved in Decision-Making as well as generally describing the levels of Medical Decision Making using the same table as CPT®

– The 1995 Guidelines do go further by establishing documentation guidance for each element of decision-making

• Number of Diagnoses or Management Options

• Amount and/or Complexity of Data to Be Reviewed

• Risk of Significant Complications, Morbidity, and/or Mortality.

With respect to this last element, the 1995 E/M Guidelines reference the Risk table, which, according to the guidance, is to be used for determining the Risk of Significant Complications, Morbidity, and/or Mortality only.

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AMA/HCFA E/M Guidelines(95)Scoring Decision-Making – Dx/Mgt Options

• DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

– For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.

– For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnoses or as "possible", "probable", or "rule out“ (R/O) diagnoses.

• DG: The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.

• DG: If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.

How Do We Objectively Score this Element Based ONLY on the Guidance Provided?

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AMA/HCFA E/M Guidelines(95)Scoring Decision-Making – Data Reviewed

The amount and complexity of data to be reviewed is based on the types of

diagnostic testing ordered or reviewed. A decision to obtain and review old medical

records and/or obtain history from sources other than the patient increases the

amount and complexity of data to be reviewed.

Discussion of contradictory or unexpected test results with the physician who

performed or interpreted the test is an indication of the complexity of data being

reviewed. On occasion the physician who ordered a test may personally review the

image, tracing or specimen to supplement information from the physician who

prepared the test report or interpretation; this is another indication of the complexity

of data being reviewed.

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AMA/HCFA E/M Guidelines(95)Scoring Decision-Making – Data Review

• DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or xray, should be documented.

• DG: The review of lab, radiology and/or other diagnostic tests should be documented. An entry in a progress note such as "WBC elevated" or "chest x-ray unremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results.

• DG: A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.

• DG: Relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of "Old records reviewed" or "additional history obtained from family" without elaboration is insufficient.

• DG: The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented.

• DG: The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented.

How do we assess the level of this element OBJECTIVELY – Especially where the documentation guidance is directory?

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AMA/HCFA E/M Guidelines(95)Scoring Decision-Making – Risk• The risk of significant complications, morbidity, and/or mortality is based on the risks

associated with the presenting problem(s), the diagnostic procedure(s), and the

possible management options.

– DG: Comorbidities/underlying diseases or other factors that increase the complexity of medical

decision making by increasing the risk of complications, morbidity, and/or mortality should be

documented.

– DG: If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of

the E/M encounter, the type of procedure, eg, laparoscopy, should be documented.

– DG: If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter,

the specific procedure should be documented.

– DG: The referral for or decision to perform a surgical or invasive diagnostic procedure on an

urgent basis should be documented or implied.

How do we assess the level of this element OBJECTIVELY – Especially since the

documentation guidance is directory?

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AMA/HCFA E/M Guidelines(95)Scoring Decision-Making – Risk

• Consider this additional instruction regarding Risk:The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

This instruction is an admission that at least the Risk element of Decision-Making cannot be determined objectively.

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AMA/HCFA E/M Guidelines(97)• The History and Decision-Making Guidance is Unchanged from the

1995 Guidelines– History can be scored objectively, Decision-Making Cannot.

• Examination– The 1997 Guidelines established detailed guidance for each organ system

as well as the general multi-system examination that permits objective analysis of the level of examination.

• Even though these guidelines get us closer to an objectively repeatable determination of the level of E/M…– 2002 OIG Fraud and Abuse Workplan Instruction resulted in few providers

following the element approach to documenting examinations and fewer auditors using this approach since it rarely results in a higher score than the 1995 Guidelines would permit.

– There remains the problem with evaluating decision-making.

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Resolving the Ambiguity

• Nature abhors a vacuum… Enter the Marshfield Tool.– Is this a binding standard?

• Marshfield does not resolve the dilemma of the EPF vs. Detailed exam under the 1995 Guidelines.

• How has this vacuum been filled?

– The 4 x 4 Rule (4 elements in 4 organ systems = Detailed Exam)

• How can this rule be reconciled with the express language of the 1995 Guidelines?

• How are elements defined? 97 Guidelines? Making such an assumption presumes that the 97 Guidelines existed when the 95 Guidelines were written, which is not true.

– What would make such ad hoc “rules” binding on a provider?

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Resolving the Ambiguity

• Marshfield does provide a relatively objective process for evaluating decision-making; however, disagreements remain.

– Auditors go beyond the express E/M guidance by requiring express documentation despite the directory (should) guidance in the E/M guidelines.

– Auditors unwilling to infer information from the record as a whole as permitted in the guidelines.

– Marshfield does nothing to clarify the ambiguity in the Risk Table

• What makes Marshfield binding on a provider?– Medicare? Commercial Payer?

– Local Medicare Contractors Posting of E/M Score sheets that are based on Marshfield?

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Resolving the Ambiguity• Common Points of Contention in Evaluating the Risk Element of

Decision-Making Even Using Marshfield– Who is to determine if the problem is acute/uncomplicated or not?– Were there risk factors associated with CV imaging studies with

contrast or not?– Were there risk factors associated with the minor surgery or not?– Does prescription management require the physician to write or

change a prescription or does reviewing the medication list in light of the findings at that visit suffice?

– What is the difference between a chronic condition with a mild exacerbation/progression and one with a severe exacerbation/progression? What if the exacerbation or progression was only moderate?

– When does a problem pose a threat to life or bodily function?

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Compliance Audits

• Disclosure Requirements under FERA and the PPACA

– Results may give an indication of a widespread error forcing the provider to do a complete or valid statistical audit to determine the total error. All overpayments must be refunded.

• For this reason, auditors must be careful when declaring error. The error must be substantiated under a binding rule.

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Compliance Audits

• Example: Provider bills 99214 to Medicare:

– Can you even use the E/M Guidelines as a binding

standard?

– Assuming you can…

• History is detailed,

• Exam is ????

• Decision making is ???

Where the ambiguity is resolved with something beyond the

guidelines, can you absolutely say the code level was wrong?

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Compliance Audits

• Example: Provider bills 99214 to Medicare:

– Assume you applied some “rule” to determine whether the exam was EPF or detailed. The audit comment may look something like…

“Examination is EPF, there is insufficient documentation (4 exam elements in 4 organ systems) to substantiate the detailed exam necessary for the level of E/M billed.”

– Not only have you created potential disclosure liability but the audit result assumes that the rule applied is binding where it likely is not. Ooops!

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Compliance Audits• Writing up your concern properly:

“Despite evidence of analysis of multiple organ systems, application of the 95 E/M guidelines produce an equivocal result with respect to the exam. The issue is whether the examination of the affected organ system is “limited” or “extended” although these terms are not defined. This carrier commonly applies the 4x4 rule (4 elements of exam in 4 organ systems) to substantiate a detailed exam even though this approach is not included in the E/M guidelines and on that is likely to conclude that the documentation does not support the level of service billed. My own subjective determination is that the examination of the affected organ system was “limited/extended.” You may consider providing more detail to avoid the expense associated with rebuttal of a down coding scenario where such a rule is improperly applied.”

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Compliance Audits• Writing up your Concerns about Decision-Making when Using

Marshfield:

“Because the E/M guidelines that are binding for this carrier do not permit objective analysis of decision-making, a scoring tool known as the Marshfield tool was utilized to evaluate decision-making. Because this approach is not contained in the E/M guidelines adopted by this carrier, the result is not an indicator of error. Instead, because this tool is commonly used as an auditing tool, it is an indicator of how a carrier auditor is likely to evaluate decision-making in this case. To minimize risk of a negative post-payment audit, it is suggested that you revise your documentation such that the decision-making result using this tool matches the DM result necessary for the code level selected.”

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Rebutting Assertions of E/M Error• Identify the Binding E/M standard – Don’t Assume that the 95/97

Guidelines are Applicable.

• Sort out the should’s from the must’s

• Identify any deviation in the audit approach from the binding standard

• Identify where the alleged error is based on the incorporation of a non-binding standard in the audit approach.– Marshfield

– 4 x 4 rule.

• Where possible, demonstrate that even if the tool used was binding, that it was misapplied/misused.

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Rebutting Assertions of E/M Error• Common E/M Auditing Errors

– Line drawing through systems in the history or examination• E/M Guidelines are largely quantitative, not qualitative.

• This documentation approach is commonly denied but is permissible under the E/M guidelines as follows:

– Complete ROS: Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

– Exam DG’s: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

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Rebutting Assertions of E/M Error

• Common E/M Auditing Errors

– Line drawing through systems in the history or

examination

• While this approach is permissible, such an approach

does raise an issue of credibility; i.e. do you believe that

the work indicated was really done?

• If this is the problem, this is the concern that should be

expressed. The statement that the documentation does

not support performance would be inaccurate.

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Rebutting Assertions of E/M Error• Common E/M Auditing Errors

– Failure to permit a physician to incorporate history by reference; i.e. “History obtained on 1/4/11 was reviewed. At todays encounter…”

• Many auditors would only score the content of the new information. CMS (where their rules are relevant) permits scoring of the new data as well as the information referenced as reviewed from a prior visit. “In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.” MCPM Pub 100-4, Ch. 12, §30.6.1.D

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Rebutting Assertions of E/M Error

• Conflicts Between CMS Pub Guidance and the E/M

Guidelines

– PIM requires MACs, CERT, RACs, and ZPICs to make

coding determinations based on CPT®. (Pub 100-8,

Ch. 3, §3.6.2.4).

– Note there is a reference to “national and local coding,

payment or billing requirements” as a basis for full or

partial payment denial. Id. at §3.6.2.5

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Rebutting Assertions of E/M Error

• Conflicts Between CMS Pub Guidance and the E/M

Guidelines

– MCPS requires that a comprehensive history always

include a review of all systems and a complete PFSH

(MCPM, Pub 100-4, Ch. 12 §30.6.1.D)

– E/M guidelines require only that the ROS involve at

least 10 systems (of 13) and for an established patient

that the PFSH address only 2 of the 3.

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Summing Up – Compliance Audits• Identify the binding E/M Standards. Don’t assume that

CPT®, 95/97 Guidelines, or any other standard is universally applicable.

• Once identified, apply the binding rules as written. Read nothing in or out. Assertions of error based on applications of external standards or based on assumptions regarding undefined terms are easily challenged.

• Delineate clear error from potential error as an issue of risk when reporting compliance audit results.

• Be cautious when drafting audit results so that you do not inappropriately create a disclosure obligation.

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Summing Up – E/M Audit Rebuttal• Identify the binding E/M Standard. Don’t assume that CPT®, 95/97 Guidelines, or

any other standard is either universally applicable or is applicable to your particular case. Check the contract, medical policy or statute.

– Where CPT® is the standard, no element of the E/M is objectively quantifiable except where the level of E/M is based on time.

– Where 95 Guidelines are the standard, identify allegations of error based on whether the exam was EPF or Detailed or any case where the allegation of error was based on the level of decision-making.

– Where 97 Guidelines are the standard, identify allegations of error based on the level of decision-making.

• Analyze the audit result and highlight each instance where the allegation of error is supported by a standard external to the guidelines or is based on an assumption regarding the meaning of an undefined term.

• Demonstrate where the external standard was misused or misapplied to create an incorrect audit result.

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