Medicare Billing Data Used by Reporters to Scrutinize Doctors’ Billing Patterns

A story in Kaiser Health News recently identified by name three California doctors as being among the top nationally for billing the most complex office visits.  CMS made physician billing information public last month on its website.

While physicians who are outliers with regard to billing patterns were always at increased risk for Medicare audits, they are now being subject to additional public scrutiny.  Billing more high complexity codes does not necessarily indicate fraudulent activity, but can instead represent a difference in the acuity of the patients treated by the physician.  However, physicians who routinely bill at the higher level evaluation and management codes should be aware of the increased scrutiny and should be prepared to defend their practices.  Physicians should be prepared to demonstrate that their medical records contain all of the required elements for the level of evaluation and management code chosen as well as documentation of the medical necessity of the level of service provided.  Educational information related to Documentation Guidelines for Evaluation and Management Services can be found on the CMS website.

Physicians should also consider using the CMS data for their own compliance efforts.  It may be educational to see where they compare to other physicians with regard to billing patterns.

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