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OIG Focusing on Emergency Department Physician Evaluation and Management Services

The U.S. Department of Health & Human Services Office of Inspector General (OIG) conducts audits every year to ensure proper federal healthcare program payments are made. OIG remains at the forefront of the nation’s efforts to fight fraud in federal healthcare programs and hold wrongdoers accountable for fraud, waste, and abuse. In a recent article published by the Health Care Compliance Association's monthly periodical Compliance Today, Angela Finnigan, Marcella Jauregi and Carla Starks discuss the addition of Medicare emergency department (ED) evaluation and management (E/M) services to the OIG work plan.


Performing audits that parallel the OIG work plan is imperative for healthcare organizations to mitigate the risk of overpayment. While services that are provided in an ED setting by physicians, nonphysician practitioners (NPPs), and facilities are reported using the same codes to report E/M services, criteria for determining the correct level of service differs between providers. This article discusses the criteria for professional fee billing for services provided in the ED setting and the difference in determining ED facility fee levels.


Conducting routine audits or reviews will help identify risk and prevent potential monetary penalties.

Regardless of the type and place of service, providers are responsible for accurately coding services.

The code set for emergency department services is CPT 99281–99285.

There are three key components that are considered when selecting an evaluation and management level of service: history, exam, and medical decision-making.

Emergency department evaluation services billed by facilities must accurately reflect the intensity of services provided and the use of resources.

Please download the full article below.

This article was originally published in Compliance Cosmos. Copyright 2021 Compliance Today, a publication of the Health Care Compliance Association (HCCA).

© Copyright 2021. The views expressed herein are those of the author(s) and not necessarily the views of Ankura Consulting Group, LLC., its management, its subsidiaries, its affiliates, or its other professionals. Ankura is not a law firm and cannot provide legal advice.


compliance, article, f-risk, healthcare & life sciences, healthcare compliance, healthcare operations

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