decisionhealth Newsletters, Coder Pink Sheets - 2011 Issue 9 (September)
Understanding E/M: 'Fast track' billing lands doctor in the slammer
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Article Overview
This article discusses a federal fraud case involving office-visit billing patterns in pain management and explains why such billing activity can attract attention from government auditors. It is relevant to physicians, coders, compliance staff, and revenue integrity professionals who monitor E/M utilization, documentation patterns, and audit risk. The article also outlines general time-based utilization concepts tied to CMS and AMA/RUC data and presents a reference table from the proposed 2012 Physician Fee Schedule.
Why This Topic Matters
It shows how billing volume and service-time patterns may be reviewed in audit and enforcement settings, making it useful for practices focused on compliance, risk management, and E/M reporting oversight.
Article Sections
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Fraud case and billing pattern overview
Introduces the federal case and the general billing pattern under review. It also frames the broader compliance concerns surrounding office-visit claims.
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Audit scrutiny and utilization risk
Explains how government auditors may identify potentially high-risk utilization patterns. It discusses broad monitoring concepts used by Medicare-related reviewers and compliance analysts.
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Calculating utilization risk from service time
Describes a general method for estimating yearly utilization from time data and billing frequency. It references CMS-released physician time information and AMA/RUC survey data.
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Physician time in minutes
Presents a reference table of office-visit time data from the proposed 2012 Physician Fee Schedule. The table is organized by code and time components.
What You Will Learn
- How a billing pattern can become the focus of a federal fraud case
- Why pain management claims may draw audit attention
- How utilization volume can be evaluated using time-based data
- What categories of CMS and AMA/RUC information are referenced for monitoring
- How a proposed fee schedule table is used as background reference material
Who Should Read This
- Physicians
- Medical coders
- Compliance officers
- Revenue integrity staff
- Practice managers
- Healthcare auditors
Codes Discussed
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