Orthopedic Coding Alert

The increasing scrutiny from third-party payers of coding in general, particularly with Evaluation and Management (E/M) Services, makes the possibility of an outside audit an uncomfortable reality. Physicians, coders and practice managers all will rest easier knowing they can pass an audit, and one of the best ways to achieve this peace of mind is by conducting regular self-audits. But beyond alleviating fear, regular self-audits also may improve your collection rate, according to Jan Rasmussen, CPC, a coding consultant and instructor for Med Learn, a medical practice management training and consulting firm in St. Paul, MN. Many coding consultants believe physicians often undercode rather than overcode. Regular self-audits can help you identify when you might ethically and legally be entitled to greater reimbursement. Here are some tips to help you conduct an efficient self-audit:

1. Review Productivity and Utilization Reports. Most coding and billing software allows you to print out reports that show which codes are being used by each physician. Rasmussen recommends going back six months if you havent done an audit in a while, and thereafter running reports and conducting a mini-audit every month. Once you have printed out reports for the time period you are auditing, examine the reports for each physician. Take a look at which codes are being used and at what frequencies, and look for red flags that will guide you into deeper investigation.

2. Search for Red Flags. As you look at the utilization reports for each caregiver (physician, PA, or nurse practitioner), take note of anything that stands out. Compare the reports to each other.

You want to notice spikes in frequency or codes that are being overused. For example, if you discover nearly all office visits by a certain physician are being coded at a level 2, but another physician has a spike in the use of level 4s and 5s, you may have a case where one is undercoding and the other is overcoding. Typically, you will see higher levels of coding in orthopedics, but a consistent run of the higher levels of service may warrant a look into the charts to be sure that the documentation justifies those codes. Contrary to the assumptions of some providers, an office visit to a specialty such as orthopedics does not automatically guarantee the higher levels.

Look for the frequencies of consultation codes (99241-99245) vs. new patient codes (99201-99205). According to Rasmussen, this is an area where E/M service codes are being misunderstood and misused, and one that might raise the attention of an outside auditor. Remember that for an E/M service to qualify as a consult, the documentation must reflect that there was a clear Reason, Request, and Reply.

Editors Note: An article [...]