Be Aware — Emergency Department Visits Under OIG Scrutiny

by  Wyn Staheli, Director of Content - innoviHealth
Jun 20th, 2023

Every year the Department of Health & Human Services Office of Inspector General (OIG) creates an official work plan giving everyone a heads up as to what they are going to be reviewing. The 2022 Work Plan stated that they would be reviewing claims for Evaluation & Management services provided in an emergency department (ED) setting because previous audits identified problem areas. The 2022 Medicare Fee-for-Service Improper Payment Report showed a 13.5% error rate with 21.4% of those related to “insufficient documentation” and 65.5% for “improper coding.”

According to the OIG Work Plan (emphasis added):

“An emergency department is defined as an organized, hospital-based facility for providing unscheduled or episodic services to patients who present for immediate medical attention. Certain Current Procedural Terminology (CPT) codes should only be used when a beneficiary is seen in an emergency department and the services described by the health care CPT coding system code definition are provided. Medicare reimburses physicians based on a patient's documented needs at the time of a visit. All evaluation and management (E/M) services reported to Medicare must be adequately documented so that medical necessity is clearly evident. This review will determine whether Medicare payments to providers for emergency department E/M services were appropriate, medically necessary, and paid in accordance with Medicare requirements.”

As noted above, one of the key review issues is whether or not the E/M service is “adequately documented so that medical necessity is clearly evident.” Therefore, it is crucial to understand both E/M service level requirements as well as what is considered “medically necessary” in order to appropriately document the encounter. 

This will get a little tricky since the codes for these services changed January 1, 2023. Although some of the rules for CPT code level selection may have changed, what CMS considers medically necessary has not changed. Join us on Thursday, June 22, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. for a free webinar covering these important topics.