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 [...]