Ob-Gyn Coding Alert

Compare your stats with these national percentages.

The nurse practitioners (NPs) in your ob-gyn office are invaluable, especially when they conduct E/M services for your practice. But could they be the cause of auditing problems down the line?

A recent comparative billing report (CBR) compiled by RELI Group, Inc., which shows that, in 2019, NPs had an improper payment rate of 8.2 percent when reporting four high-level E/M codes, suggests that could be the case. However, the report also includes important data that you can use to compare with your own to determine if your NP E/M usage might be creating red flags.

Here’s all the metrics and advice you need to head such issues off at the pass.

Where the Problems Exist

The four codes and their respective improper payment amounts for NP services were:

• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity …): 15.3 percent improper payment rate, representing over $203 million;
• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity …): 18.8 percent improper payment rate, representing over $93 million;
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …): 5 percent improper payment rate, representing over $423 million; and
• 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity …): 9.9 percent improper payment rate, representing over $108 million.

The RELI team, which the Centers for Medicare & Medicaid Services (CMS) contracts to develop, produce, and distribute CBR reports, then analyzed NP claims for these E/M services that were submitted between February 1, 2019 and January 31, 2020.

Check the Percentage of Allowed Units

“Metric 1 looks at the percentage of allowed units for new and established patient E/M levels 4 and 5,” noted RELI’s Annie Barnaby during a June 29, 2020 presentation on the topic. “This metric tells us, of all the E/M services performed through the analysis year, what percentage of those were for these high-level service codes?”

To find these numbers, the analysts divided the total number of allowed units for each of the individual CPT^® codes separately by the allowed units for CPT^® codes 99201-99205. Those results were then multiplied by 100 to get the percentage.

The national rates of allowed units for these codes were:

• 99204: 33.48 percent
• 99205: 5.08 percent
• 99214: 48.95 percent
• 99215: 3.62 percent

Practices should compare their stats with these national percentages. If you are significantly higher than the averages, it’s possible that reviewers may soon be scrutinizing your claims. For instance, if 40 percent of your NP’s established patient office visits were billed with 99215, then they are significantly higher than the average.

Red flags: When reporting E/M services, if you are constantly reporting the same E/M code (such as 99214) for every E/M encounter that your NP performs, then you will be inviting trouble. You might soon end up facing an unnecessary audit and other problems if you just report the same E/M code for every E/M encounter.