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Evaluation and Management (E&M) services are the backbone of most physician practices, comprising up to 35% of office-based claim payments for physician services in the United States, also known as professional claims. Based on both objective and subjective criteria to determine the complexity of the visit, a provider chooses the appropriate level for each code—and the higher the level, the greater the reimbursement.
It’s no surprise, then, that E&M claims comprise a significant payment integrity challenge for payers. The problem also extends to emergency room (ER) facility E&M claims. A Cotiviti analysis across commercial, Medicare, and Medicaid clients demonstrates a significant rise in Level 4 and 5 claims submitted in the last five years and a corresponding decrease in lower-level claims. Given this increase, there is a major likelihood of over-coding and inflated costs that can be difficult to recover.
In a new white paper, Cotiviti Chief Medical Officer Richard Pozen, M.D., explains how an approach that combines machine learning and advanced analytics with expert nurse coder review delivers significant savings for payers—and enables them to pay even the most complex E&M claims promptly and appropriately while minimizing the potential for provider pushback.