a physician upcodes or downcodes an evaluation and management
claim, most of the time it's only by one level. That should
be considered a matter of professional judgment, because
even Centers for Medicare & Medicaid Services officials
can't always agree on the correct E/M level for a particular
visit, says a spokesperson from the American Medical Association.
most recent House of Delegates meeting, the AMA urged CMS
to give physicians relief from fraud -and abuse witch-hunts.
The AMA suggested that if a physician is only one level
off the correct E/M level, this shouldn't count as fraud
AMA resolved to work with the HHS Office of Inspector General
to clarify the criteria that would trigger a Medicare audit,
and establish new rules spelling out the physician's rights
in case of an audit. Also, the Delegates resolved that the
AMA should "advocate forcefully" for CMS and the
OIG to end all random review of E/M services and to consult
with independent peer reviewers before doing any post-payment
audits of E/M services.
the AMA will seek legislation or regulations that will make
clear that E/M coding is imprecise by nature and audits
should give credit for downcoding along with upcoding.