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Expansion of E&M Auditing In June 2000, the Health Care Financing Administration (HCFA) announced that it would focus the local Medicare carrier's Evaluation and Management (E&M) coding efforts on 99214 – a moderately high medically complex subsequent office visit, and 99233 – a high medically complex subsequent hospital visit. The government is currently expanding its E&M auditing to new patient office visits (99201-05) with attention to 99204 and 99205. The audits will also include the inpatient hospital consults (99251-55), with attention to 99254 and 99255. Upcoding without the supporting documentation may lead to refunds and monetary penalties three times the original charge, plus penalties from $5,000 to $10,000 per claim. In-patient consults require a referring physician to be named in the introduction or narrative of the written report and findings. New patient office visits do not require a referring physician. All E&M services require supporting detailed documentation of the three key elements: history, exam, and medical decision. Continuous utilization of one code, whether at the low or higher end of the category sequence may spark the interest of a carrier to request documentation. For further documentation details call the Office for Billing Compliance, and visit its website at http:/cpmcnet.columbia.edu/dept/compliance. All letters requesting documentation or refunds must be sent to the Office for Billing Compliance, BB 2- 239, for response coordination.
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