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The Perils of E&M Codes and Insurance

Knicole C. Emanuel, Esq.

Lately, I have been inundated with Medicare and Medicaid healthcare providers getting audited for evaluation and management (E&M) codes. I know Dr. Hirsch (Ronald Hirsch, MD) has spoken often about the perils of such codes. The thing about them is that everyone uses them: hospitals, family physicians, urgent care centers, and specialists.

Obviously, for a specialist, like cardiology, the higher-level codes will be more common. A 99214 will be common, compared to a generalist like a primary care physician, whereby a 99213 may be more common.

Here’s a little secret: the difference between 99214 and 99213 is subjective. It’s so subjective that I have seen auditors hired by private companies to audit on behalf of the Centers for Medicare & Medicaid Services (CMS), making them financially incentivized to find fault, find 100-percent error rates. Who finds a 100-percent error rate? Not one claim out of 150 was compliant

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This article originally published on May 31, 2023, by RACmonitor.