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Study finds Medicare overbilling may be caused by government's faulty reimbursement

Washington, DC--In the midst of an ongoing crackdown on health care providers for allegedly overbilling federal health care programs, a study in the September 2002 Annals of Emergency Medicine finds the government's coding system used to determine physicians' Medicare payments is an unvalidated process prone to errors. (Reliability of Assigning Correct Current Procedural Terminology--4 E/M Codes)

"The American College of Emergency Physicians strongly supports government efforts to remove fraudulent practices from the Medicare program," said Michael L. Carius, MD, president of ACEP. "But the truth is that most of what the government calls fraud and abuse results from simple billing errors and the problems inherent in complying with Medicare's more than 100,000 pages of rules and supporting documents."

Nearly 9,000 Current Procedural Terminology (CPT) codes are used in the medical field to code medical procedures for Medicare claims. The codes describe the extent of a physician's interaction with a patient, such as obtaining the patient's medical history, performing a physical examination, and providing various levels of medical services. Each code is tied to a payment amount. The more complex the interaction between the patient and physician, the higher the code and level of payment.

This study focuses on the five evaluation and management (E/M) codes that represent 70 percent of the codes emergency physicians use to bill for the services they provide. E/M coding has received extraordinary attention by government auditors. The study's authors explain this is because most claims are billed under these codes, which represent less tangible services and have less precise definitions than other codes, opening them up to broader interpretation, and thus inviting more scrutiny.

To determine the reliability of the federal government's E/M coding system, Raymond E. Jackson, MD, and his team of investigators from William Beaumont Hospital Syste
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Contact: Colleen Horn
chorn@acep.org
202-728-0610
American College of Emergency Physicians
22-Aug-2002


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