Orthopedic Coding Alert

Because U.S. 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," says Gary Meza, chief executive officer of Advanced Orthopaedic Centers, an 11-orthopedist practice in Richmond, Va. "Conversely, those physicians who are undercoding to stay on the safe or conservative side could be losing a significant amount of legitimate revenue." Why E/M Benchmarking Works According to Frank Cohen, senior analyst at Medical Information Technology Systems, a national healthcare consulting firm, 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, such as arthroscopic medial meniscec-tomies (29881), the actual numbers depend on your population base. "If you're in an older population base, the chances of your doing a lot of those surgeries is much lower than if you're in a younger population base. So benchmarking, unfortunately, may not be an exact science because it cannot take into account all the idiosyncrasies in the population base."

Consequently, most consultants recommend performing an E/M comparison study because all orthopedists perform at least some type of E/M services. CMS lists the raw data on its Web site from which you can filter out the information for orthopedic surgery and calculate percentages. We have compiled this information for the most commonly billed E/M codes, listed at right.

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, recommends using this data in three ways: 1. Review Data Across Categories. For instance, Sandham suggests, determine the relationship between outpatient consultations (99241-99245) and new patient office visits (99201-99205), then compare that to the national averages using the CMS database. If you are billing more consults than new office visits, your practice may be confusing referrals with consultations.

The point here isn't to suddenly start billing all of your consults using new patient codes, Sandham says, but to provoke orthopedic practices to review records to ensure that the charts are being coded correctly. 2. Review Data Within Categories. For example, compare your range of established office visit codes to Medicare's. Although your practice may bill mainly 99212s, CMS suggests that the average orthopedic practice bills more 99213s. This should inspire you to determine whether you routinely undercodes claims.

3. Review Data Per Code. For instance, compare your practice's use of 99214 [...]