Published 8/1/2009
Mary LeGrand, RN, MA, CCS-P, CPC; M. Bradford Henley, MD, MBA

Are you an E&M outlier?

Benchmarking yourself can show variations in practice patterns

No orthopaedic practice wants to become the subject of a billing audit by the Office of the Inspector General (OIG) or a Medicare Recovery Audit Contractor (RAC). But certain office procedures—such as how you schedule and code postoperative visits that occur immediately after the end of the global billing period and how well you adhere to the Medicare Global Surgical Package rules associated with the reporting of “related” postoperative problems—can increase your risk of such an audit. (See “Check your schedule for an audit time bomb,” July 2009 AAOS Now.)

As you review your procedures to ensure that you are properly coding such visits, take some extra time to examine the frequency of your evaluation and management (E&M) code usage. Are the levels of service you report for new, established, and consultation services dramatically different from those reported by your partners and other orthopaedic surgeons?

Comparing each doctor in a group to the state or national Medicare data is a way to see if your code usage is a flashing yellow light for auditors. By taking the time to analyze your E&M services coding, you’ll find out whether your coding marks you as an outlier and whether the documentation you have supports the codes you claim.

Variations are a clue
The OIG may discover you are an outlier before you do if you don’t take this seriously and determine how your practice patterns compare to benchmark data. Or, if the OIG does not identify your practice as an outlier, chances are you may fall victim to CERT (Comprehensive Error Rate Testing) reviews that will identify your billing patterns as those of an outlier when compared to your peers.

Figure 1 shows how benchmarking E&M codes against national or state norms can mark a physician as an outlier. In both new patient visits and established patient visits, Dr. Green has a variance in code distribution at level 3 visits (99203, 99213) and level 4 visits (99204, 99214) compared to national and state benchmarks. He also shows a variance at level 2 established patient visits (99212).

Distribution variances like these are what payors look for in determining which practices require a billing audit. If your practice shows a gap, you need to review your coding to ensure that the work and documentation support the level of services being claimed.

Getting started
The following tips will help you get started:

  • Analyze E&M CPT code distribution. Run a frequency report for new patients, established patients, and consultation visits by doctor. See where your services fall in comparison to benchmark data. Visit www.karenzupko.com for information on KZA’s E&M Analyzer tool that makes it easy to compare your results against state data.
  • Develop an internal compliance and monitoring plan to identify risk areas in your billing practices. You want to be able to identify risk areas before payors do.
  • Review your payor contracts to determine their requirements for reporting postoperative visits related to the surgical procedure during the global period.

Optimizing your reimbursement is critical during these economic times, but not at the risk of incorrect coding or billing activities. Code accurately, submit dictation and claims on a timely basis, and ensure accurate claim submission to payors—you’ll minimize risk, be paid faster, and reduce the risk of recoupment requests.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., and focuses on coding and reimbursement issues in orthopaedic practices. M. Bradford Henley, MD, MBA, is a member of the AAOS Coding, Coverage, and Reimbursement Committee.