Evaluation and Management Coding Program

July 2021

We review the use of evaluation and management (E&M) coding practices on claims submitted by participating health care providers to monitor for potential upcoding. This program is part of our ongoing efforts to help improve health care quality and affordability.


What is upcoding?

Upcoding is the practice of using billing or revenue codes that describe more extensive services than those actually performed or documented, as defined by the Centers for Medicare & Medicaid Services (CMS).

  • Example: CPT code 99205 (new outpatient visit highest level) is billed for a patient who came in for a sore throat, had a throat culture, and was put on penicillin. The 99205 code would require that the medical decision making level was determined to be high or the total time for the evaluation and management service performed on the date of the encounter was 60-74 minutes in length because of medical necessity.
  • A sore throat evaluation and management visit as described above would be more appropriately coded as 99202 (new outpatient visit lowest level) based on documentation guidelines from the CMS Evaluation and Management Services Guide. The 99202 code would require that the medical decision making level was determined to be straightforward or the total time for the evaluation and management service performed on the date of the encounter was 15-29 minutes in length because of medical necessity.

Health care professionals should, consistent with standard industry practice, select the CPT code that best represents the level of service performed when submitting claims for payment.


E&M upcoding evaluation process

We have developed a process for reviewing claims specific to E&M coding. As part of this process, claims are evaluated and billing practices are compared to those of a health care provider's peers within the same primary specialty and in the same community. Statistical analysis is conducted and health care providers whose billing practices on submitted claims differ from their peer group are evaluated further.


Outreach

We may contact health care providers who differ from their peer group for further evaluation. We generally send those providers a letter and report.
In some cases, including those when E&M results demonstrate consistently high outlier utilization, a Cigna Market Medical Executive may also contact the health care provider.
This outreach may include a telephone call, a meeting request, or a discussion initiated during a meeting scheduled for another purpose. In rare cases, a chart review may be requested and performed. The goal is to help educate health care providers about improving their coding practices.
Most health care providers will not be affected by the E&M program and will not be contacted.


Questions and answers

  1. What is the purpose of the E&M coding initiative?

    As part of our process, we routinely review claims to help ensure coding and payment accuracy. This initiative was implemented to increase awareness about submitting accurate coding and appropriate charges for the services performed and documented.


  2. How are outliers determined?

    Benchmarks and outliers are determined at the market level. Claim data is reviewed against programmed E&M coding parameters and reports are run to identify health care providers whose claims are different than those of their peers. Using the content in the report, a performance index (PI) is calculated for each health care provider. The PI is defined as the health care provider’s average relative value unit (RVU) divided by his or her peers’ average RVU. Outliers are those participating health care providers whose PI is at least 2.0 standard deviations from the market average, and who have billed a minimum of 30 E&M services in the past year.


  3. What is RVU?

    RVU is a measure of effort and expense associated with providing a procedure. This includes the time required to perform a service, technical skill and physical effort, mental effort and judgment, and psychological stress associated with the health care provider's concern about the risk to the patient. RVU is used as a factor in calculating the total payment, along with other items such as practice expense and malpractice insurance.


  4. What is a PI?

    A PI is a calculation of the health care provider's average RVU per service divided by peer average RVU per service. For example, a health care provider with a PI of 1.10 should have done 10 percent more work than his or her peers.


  5. What is standard deviation?

    Standard deviation is a measurement of variability that is widely used in statistics. It shows how much variation there is from the average or expected result.


  6. What is the total work variance?

    The total work variance is a final score that indicates a health care provider's intensity of services. Generally, a score greater than zero means the health care provider is submitting claims for higher intensity services than his or her peers. The total work variance is defined as the difference between the health care provider's average RVU per service and peer group's average RVU per service multiplied by the total services.


  7. What health care provider specialty types are most affected by this initiative?

    All health care providers who submit claims using E&M codes are reviewed through this initiative. However, health care providers who consistently submit claims using higher complexity E&M codes will most likely be affected by this initiative.


  8. What CPT codes are reviewed for this initiative?

    We review the following CPT codes:

    Service type CPT® codes
    Critical care 99291, 99292
    Emergency room services 99281, 99282, 99283, 99284, 99285
    Office/outpatient visit, established 99211, 99212, 99213, 99214, 99215
    Office/outpatient visit, new patient 99201, 99202, 99203, 99204, 99205
    Telephone and internet services 99441, 99442, 99443, 99444
    Domicile/Home Visit, new pt 99324, 99325, 99326, 99327, 99328
    Domicile/Home Visit, estab pt 99334, 99335, 99336, 99337
    Home visit, new pt 99341, 99342, 99343, 99344, 99345
    Home visit, estab pt 99347, 99348, 99349, 99350
    Prolonged services 99354, 99355, 99356, 99357, 99358, 99359
    Smoking Cessation 99406, 99407
    Prolonged Clinical Staff services, Phys or other HCP 99415, 99416
    Online Digital E&M services 99421, 99422, 99423

  9. Additional information

    For additional information about CPT coding, visit the American Medical Association website (Ama-assn.org > Resources > Solutions for Managing Your Practice > CPT Coding, Billing, and Insurance > CPT). Additional CPT resources are available from the American Medical Association online at Amapress.org, or by calling 1.800.621.8335.

    For questions about our E&M coding program, please email PhysicianEvaluationInformationRequest@Cigna.com, or fax to 1.866.448.5506.