ED Coding and Reimbursement Alert

Boost your practice's coding accuracy with concrete data from national stats

Because HHS Office of Inspector General (OIG) investigators review code utilization data - also called "benchmarking" - you should beat them to it by comparing your code usage to national averages and identify any problem areas.
 
Just like HMOs, Medicare reviews coding practices and looks for disparities or red flags, such as physicians whose visits are consistently at the higher levels of coding. Those physicians who undercode to stay on the safe or conservative side could be losing a lot of legitimate revenue. Seeing where your practice falls can help you reassess your coding accordingly.

Why E/M Benchmarking Works

According to Frank Cohen, senior analyst at Medical Information Technology Systems in Clearwater, Fla., and author of The E/M Bell Curve, not all benchmarking is beneficial to your practice. For instance, if you try to benchmark your practice's use of a specific procedure code (compare your code usage to the national average), the actual numbers depend on your population base.

For instance, if your practice has an older population base, chances are your E/M frequency distribution will be skewed toward higher levels of acuity, based on the likelihood of your typical patient being older and sicker than average. So benchmarking, unfortunately, may not be an exact science, because it cannot take into account all the idiosyncrasies of the patient population of any given facility.
 
What to do: Most consultants recommend performing an E/M comparison study because all emergency department physicians perform E/M services. CMS lists the raw data on its Web site, from which you can filter out the information for emergency medicine and calculate percentages. For the most commonly billed E/M codes in the ED, we calculated what percentage each code constitutes out of all the ED E/M codes reported in 2003 (see chart at right). 

You should use the information from this chart to review your data within categories, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.

For example, compare your number of level-three E/M codes (99283) to Medicare's. If your practice bills more 99282s than the average suggested by CMS data, but not as many 99283s, you might want to examine your charts to determine whether you routinely undercode claims, or whether demographic or environmental information contributes to the skew.

Don't Take CMS Averages as Gospel

While your practice may benefit from comparing its coding to national averages, you shouldn't change your coding practices just to stay within the averages, Sandham says. "If you have a higher utilization profile, you may be treating sicker patients," he says. For example, if you work in a major trauma center, it is understandable that you would have a higher percentage of level-five visits or critical care than the average practice.
 
And Medicare draws its statistics from unaudited data, so not every code included in the averages is a correct description of the patient's service. Also, keep in mind that the CMS data are all Medicare, and your practice is not. Be sure to compare your distribution to other emergency physicians for an accurate "apples-to-apples" comparison.

Compare Your Practice to Itself

The best advice for benchmarking is to compare your practice's code use for one time period against your data for another period. For instance, compare your data from January through June to your statistics from July through December. This way, you can determine code use across the board - E/M codes as well as procedures. If the comparison shows a big change in the way your practice billed, look further to determine why. You may be coding more or less accurately now than you were six months ago, and knowing the reason can help you improve.

Caution: Keep an eye on compliance when comparing annual utilization statistics so you aren't tempted to say, "We billed more high-level codes last year, so let's code more of them this year."

Sandham also recommends comparing physicians' utilization individually: "Compare each physician in the practice to the group as a whole, then to CMS. Even though you may be on track with CMS' data, you may find that one physician in your practice is billing too high and another is billing too low - this would put you on average in the middle, but it doesn't mean that the physicians are correctly coding."