Medicare Compliance & Reimbursement

Tip: Benchmark your stats against those of other specialists to fix E/M faults.

Denial rates suggest that Medicare claims reviewers aren’t going to stop targeting E/M service codes any time soon. Moreover, if your practice falls outside the state and national averages for use of these codes for whatever reason, you may need to step up your compliance to avoid having your claims pulled for a Medicare audit.

Context: “The purpose of the Comparative Billing Report [CBR] is to show providers/suppliers their specific billing pattern data in comparison to peer groups within the state” and the jurisdiction they practice in, says Medicare Administrative Carrier (MAC) CGS in online guidance.

For example, if a MAC looks at E/M coding percentages — which show the range of codes billed from low-level to high-level — the MAC will scrutinize the curves that are heavily weighted to the high side because they’ll look for whether the practice was overpaid. However, many carriers are also looking at those practices that err to the low side of the curve because that also indicates that incorrect coding might be happening.

It’s a good idea to keep an eye on the CBRs that your Part B MAC releases to see where you fall. Most Medicare contractors post these on their websites in an effort to educate the provider community about the averages.

You can request a personalized CBR specific to your Provider Transaction Access Number (PTAN) or National Provider Identifier (NPI) based on the date of service and the HCPCS or CPT^® code you plug in. The MACs usually accept these requests through their jurisdiction-specific web portals, so check with your MAC on the particulars.

Use the following three tips to ensure that you maximize CBR data specific to your expertise.

1. See Where Your Practice Falls

Reviewing CBRs allows you to determine whether your billing habits are similar to other practitioners’ nationwide. The statistics are broken down by specialty, so if you’re a family practitioner, you don’t have to compare your E/M billings to urologists — you can check just the family practice details.

Reminder: Keep in mind that practices that are billing significantly higher codes aren’t necessarily defrauding Medicare. If you fall into this category, you might be treating sicker patients, and therefore, may not have the same insurance case mix as other practices. The information in the comparative billing files includes Medicare patients only — and since you probably see patients from Medicare, Medicaid, private payers, workers’ compensation, and other sources, your case mix will be different.

However, the data is still helpful as an overall view of where your coding patterns may fall. Once you download the CBR from your MAC, look for your specialty designation to see what the average coding patterns are for specialists like you in your state and across the country.

2. Pull Charts at Random for Best Audit Results

Reading your CBRs should be a springboard to auditing some of your practice’s files by selecting random charts and reviewing them to determine whether the correct E/M code was reported in each encounter note.

During your self-audits, check the chart documentation on the randomly-sampled, determine which E/M code you would report for the service, and then check what the physician actually billed. Keep a tally of any discrepancies so you know what to discuss with the doctor later, when you can offer the physician tips on how to select the right E/M code.

Again, your numbers may fall outside of the norms for your specialty, and that’s okay as long as the documentation supports the codes billed and you can find justification of the medical necessity for each visit in the notes.

MAC advice: Lackluster documentation mixed with coding issues leads to dashed E/M service claims and bumped up improper coding rates, according to Part B MAC WPS GHA. And, that’s why the Medicare carrier advises practices to self-audit.

“For providers to ensure that claims are submitted appropriately, an ongoing evaluation process is important,” WPS GHA explains. “A self-audit is an excellent way for a physician practice to ascertain if any problem areas exist which may warrant further education or corrective actions. A complete and successful self-audit evaluation includes both a standards and procedures review and a claim submission audit.”

3. Measure Your Stats Against Local Peers

Once you’ve compared your practice to other specialists in your area, another smart tactic is to compare the practitioners in your practice to one another.

Coding insight: Most practices’ coding habits fall in line with the national averages, but closer inspection often reveals that one physician habitually overcodes while another undercodes too often, thus leading to the misleading “normal” averages, coding experts say.

If after a thorough review, you find practitioners whose charts fall well outside the curve, examine whether they are billing appropriately or not. If their codes match the documentation, there’s no need to worry. But if they seem to be miscoding a lot of files, it’s time to take that clinician aside and offer some E/M selection education.

Don’t Forget to Mobilize Your EHR for Benchmarking, Too

Many EHRs produce charts and data that can be used for auditing, benchmarking, and more. “Most practice management systems should be able to generate frequency of usage of CPT^® different codes,” says Vinod Gidwani, founder of Currence Physician Solutions in Skokie, Illinois. “These reports may be subtitled CPT^® code productivity by doctor, facility, etc.”

Once you run your reports, use the data that you glean from them to plug numbers into the average benchmarking calculations, and you’re on your way to creating a system-wide benchmarking program for your physician practice.