Contractors who administer and review claims for the Centers for Medicare & Medicaid Services (CMS) seem to focus a lot of attention on the level of evaluation and management (E/M) services reported on claims, in contrast with claims reporting codes from the remainder of the Current Procedural Terminology code set. This is explained by the percentage of services that are reported with E/M codes, continually high error rates in focused reviews by the Comprehensive Error Rate Testing program, and complexity of the associated guidelines. But while CMS contractors may be the leader in E/M coding reviews, Medicaid plans and private payers have similar integrity programs that often take a similar approach to claims auditing.

One area that may result in errors with Medicare and other payers is not getting credit for a complete review of systems (ROS) in the history component of an E/M service. Many physicians document positive and...

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