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March 2011


Evaluation and Management Coding Review

CIGNA will review Evaluation and Management (E&M) coding in 2011. We review the use of E&M coding practices to monitor for potential upcoding as part of our ongoing focus on helping to improve health care quality and affordability. Upcoding is the practice of consistently using billing or revenue codes that describe more extensive services than those actually performed, as defined by the Centers for Medicare and Medicaid Services (CMS). CIGNA expects physicians, consistent with standard industry practice, to select the CPT code thatbest represents the level of service performed when submitting claims for payment.

CIGNA has developed a process for monitoring physician billing practices specific to E&M coding. As part of this process, claims are evaluated and physician billing practices are compared to the claims of the physician’s peers. Statistical analysis is conducted and physicians whose billing practices differ from the peer group are evaluated further. Physicians who differ from the peer group may be contacted by CIGNA for further evaluation. This additional contact may be in the form of a letter and report, a telephone call or a meeting request. In some cases, chart review may be requested and performed. For most CIGNA-participating health care professionals, this program will not result in additional communication or interactions beyond this article.

Additional Information

For additional information about Current Procedural Terminology, visit: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.shtml.   

Current Procedural Terminology is available from the American Medical Association. Visit http://www.amapress.org or call 1.800.621.8335. graybullet




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