Medicare contractors eyeing evaluation and management patterns among urologists, other physicians


The government has contracted with a number of different companies (eg, recovery audit contractors, zone program integrity contractors, and Medicare contractors) to look at all Medicare payments and try to detect billing patterns that are outside the norm.

Q I recently received a letter from my Medicare carrier indicating that I am charging more high-level evaluation and management (E&M) codes than the average urologist. The carrier did not ask for any charts, nor did it ask me to pay any money. What will happen next? What should I do?

You should not simply change your billing pattern to try and match the curve. We still strongly recommend that you provide the services you feel are medically necessary, document what you do, and charge what is documented.

This latest set of letters raise a few areas of concern:

Payers have used numerous sources to develop guidelines similar to those developed by Medicare. A common source for payers is CPT. Medical necessity as it relates to E&M codes is addressed in the E&M codes and guidelines in CPT. Interpretation of these guidelines will provide the jumping-off point for medical necessity as it relates to E&M codes. We suspect that Medicare will use ICD-9 codes as a filter for audits but will have to use the CPT interpretation as enforcement. The letters from the carriers seem to indicate that higher-level E&M codes are justified only for services provided to those presenting with problems that will result in death or disability before intervention or the next visit. Clearly, this interpretation will have to be refined. We will keep you up to date as we are provided more detail.

In the end, both payers and providers will have to adapt to the change in medical practice caused by EHRs. From the physician office, you must guard against the quick fix and maintain coding discipline and a compliance culture that will allow you to be paid accurately for the services you provide.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at

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