Orthopedic Coding Alert

Benchmarking can help you determine whether you're on track

If you want to find out whether you're at risk for an insurance audit - or whether you're leaving money on the table by undercoding, look no further. Benchmarking can help you compare your practice against other orthopedic offices to determine whether you're coding above or below normal levels.

Most consultants recommend that practices should at least perform a comparison of their E/M coding against other orthopedists' E/M usage. That way, you'll know whether you are always billing higher or lower than the norm, and if so, you can make sure you're justified in billing outside of the averages.

"You need to know what other like practices are doing - how your peers are performing and where their reimbursement is coming from, so you'll know how you're doing," says Lauree Handlon, RHIA, CCS, CPC-H, senior coding/billing analyst at Cleverley Associates, a healthcare consulting firm in Worthington, Ohio.
To check out CMS benchmarking data for orthopedists, see our chart, "CMS' Orthopedic Data Can Get Your Benchmarking Study off the Ground" later in this issue.
 
Factor in Your Patient Base

You can find raw Medicare utilization data on the CMS Web site, which breaks down the data by specialty. "It's important to look at the different case mix among the physician specialties, because you may be treating sicker patients or less sick patients than other specialists," Handlon says.

In addition, you may be treating a specific patient base that requires higher-complexity visits than the average orthopedic surgeon. For instance, if you work for an orthopedic trauma surgeon, you're more likely to bill higher-level visits than a practice that mainly handles sports medicine. Therefore, benchmarking may not be an exact science because it cannot take into account all the idiosyncrasies in the population base.

However, you can take steps to "normalize" the data. See our article, "Determine Practice's Complexity Level to Normalize Stats" for information on how to extract your acuity factor.
 
Don't Blindly Follow the Leader

Practices should never change their coding practices just to stay within the averages, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky. "Even if you're coding at higher levels than other orthopedic surgeons, you may still be coding accurately," she says. "Benchmarking gives you a good jumping-off point for discussion. If you're billing mostly 99215's, you'll need to look at your records and make sure those codes are justified. And if you're billing all 99212's, you should make sure your documentation doesn't support a higher code in some instances."

One effective benchmarking tactic is to compare your practice's code use for one time period against your data for another period. For instance, compare your code usage from January through June to your statistics from July through December.

If the comparison shows a big change in the way your practice billed, look further to determine why. You may be coding more accurately now, or vice-versa. 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."

In addition, you should compare physicians' utilization to the group as a whole, then to CMS data. 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.