ED Coding and Reimbursement Alert

Use these tips to defend your distribution.

Payer expectations for a normal ED distribution can target your practice for audits, but applying such tactics as asking auditors to provide comparison details can help promote your cause.

Here's the scoop. One way payers routinely identify providers for audits is by comparing the frequency distribution of their E/M codes to a broad standard of other providers. Frequency distribution just means tracking the utilization of each code in question as a percentage of the group of codes. In the ED setting, the ED E/M codes and critical care (99281-85 and 99291) are usually considered as a group. Although many payers expect to see a normal "bell curve" distribution, that is not typical in the ED setting. Very few patients come to the ED with low level presentations because of the high copayments and potential long wait times due to triage protocols. Consider the national Medicare distribution from 2009, the last year from which the complete data is currently available from the Medicare Part B Summary Data file (formerly known as the BESS data).

Keep in mind: This distribution is for Medicare patients only and may skew a little higher in acuity than a universal patient population. A Medicaid only distribution might skew towards lower acuity because many Medicaid patients come to the ED for less acute visits based on limited access to other providers who will see them. Additionally, the Medicare distribution is only for those providers that identify themselves as emergency physicians using specialty identifier 93. This is an important consideration in that an emergency physician distribution may well differ significantly from that of a PA, NP or moonlighting Family Physician.

Get Distribution Details to Minimize Your Audit Risks

"Ask any auditors that claim you are an outlier to explain exactly what distribution was used for comparison and when the data was collected." suggests Ed Gaines, JD, CCP, Chief Compliance Officer for Medical Management Professionals, Inc. in Greensboro, N.C. "It may turn out that you are not really an outlier when compared to a population more in line with your ED practice. For example, if a physician worked only in a Level I trauma center, it would not be surprising that they had a very high level code distribution. Similarly, if a physician only worked in a fast track area, their distribution would likely reflect higher percentages of levels 2 and 3 ED E/M codes."

Request that the auditor inform you that the distributions they used for comparison purposes are for emergency medicine specialty 93 and not other specialties for a true "apples to apples" comparison, adds Gaines. Don't assume that other specialties that can bill the 9928x codes have been excluded from the comparison.

Track Sites To Justify E/M Levels

Medicare Area Contractors (A/B MACs, formerly Part B Carriers) may also provide ED groups with the distribution of E/M codes by group or by individual provider according to the "Comparative Billing Report" (CBRs). For example, the Florida MAC, First Coast Service Options, explains in detail how a provider group would request their CBR at the following link -- http://medicare.fcso.com/CBR/138607.asp

The Medicare Program Integrity Manual provides that the MAC, CERT, ZPIC or other contractor may use the CBR as the basis to conduct a "probe review". Probes are typically between 30-100 records where the Medicare contractor will review the E/M coding and claim submissions in an initial Medicare audit known as "Medical Review."

RACs, in contrast, are subject to separate rules and policies in terms of the number of records selected and are expressly prohibited from conducting "pre-payment" medical reviews known as "complex reviews" on prebilled claims; complex reviews can be done on a postpayment basis.

Don't Forget These Additional Considerations for Distribution Differences

Even if you are an outlier, it doesn't mean that you are committing fraud or doing anything wrong. However, it will increase the chances that your charts will be identified for further review.

You should track your E/M distribution, and if you do appear to have a higher acuity distribution, identify your site specific acuity predictors which might include:

• Trauma services
• Cardiac catheterization program
• Stroke center
• Specialty services such as hand surgery, dialysis and neurosurgery
• Regional referral center such as for poisonings, pediatrics, or burns
• Urban location