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 [...]