January 1997 Bulletin

Practices must review E/M coding
Orthopaedists must know profile; payers use it for audits

By Ann Bullis

We view our practices as surgical in nature and typically spend more time and focus coding our surgical procedures. Orthopaedics, however, is an unusual specialty, because 15-25 percent of our total charges are generated from office visit codes. A national trend has been the increased value of CPT office visit codes (evaluation and management-E/M) and the decreasing value of the surgical procedure codes. It would seem likely that a target for review both internally and from external sources, would be the E/M codes.

There are many advantages to reviewing your individual and group E/M profile. In many practices today, we have to be prepared to negotiate for the discounted fee for service as well as defend our utilization patterns for capitated contracts. To better understand our position for negotiations and allow the E/M codes to work to our advantage, it is helpful to know where we fit in the norms for other practices.

Payers also use the E/M coding profiles of billing information systems to analyze coding patterns. They will audit individuals and groups based on data submitted. Every Medicare carrier has software, "Focus Med Review Technology," that can determine if the surgeon's coding profile is unusual in terms of frequency and coding level. Your practice could be in a weakened position if you don't have the supporting documentation for abnormal profiles should your pattern of coding trigger an audit.

The table shows the percentages of total encounters for 15 common types of office visits for a collective 82.32 FTE orthopaedic surgeons for a 12-month period. This information was obtained from Medical Group Management Association (MGMA), Center for Research and Ambulatory Healthcare Administration's Physician Services Practice Analysis Comparison1995.

Given this data, I have compared the profiles of six different orthopaedic groups in Northern California. Within these groups, there was a variation both by group and individual physicians. The collective MGMA data is helpful for comparison value, even though it did not reflect their patterns. It gives them targets, a basis for discussion and support data for continuing evaluation of individual and group coding practices.

The following are some suggestions to improve the coding for E/M:

The importance of accurate coding is imperative for reimbursement, value measurement and practice analysis. Internal data analysis and external benchmarking gives surgeons and practice managers one more tool to better understand audits and negotiations.

Ann Bullis is a Certified Medical Practice Executive and Administrator for Western Orthopedics Management Group, Inc., Davis, Calif.

E/M CPT-4 codes



Percent
frequency
99201 Office Visit
New Patient Level 1
8
99202 Office Visit
New Patient Level 2
31
99203 Office Visit
New Patient Level 3
50
99204 Office Visit
New Patient Level 4
9
99205 Office Visit
New Patient Level 5
2

Total 100



99211 Office Visit
Established Patient Level 1
2
99212 Office Visit
Established Patient Level 2
40
99213 Office Visit
Established Patient Level 3
51
99214 Office Visit
Established Patient Level 4
5
99215 Office Visit
Established Patient Level 5
2

Total 100



99241 Consult new or
established patient Level 1
10
99242 Consult new or
established patient Level 2
59
99243 Consult new or
established patient Level 3
20
99244 Consult new or
established patient Level 4
8
99245 Consult new or
established patient Level 5
3

Total 100


Percent frequencyThe percentage each visit represents of the five visits shown for the following categoriesNew Patient Visit, Follow up Visit, Consultation. ExampleFor orthopaedists, of the five levels of Initial visits, 8 percent were 99201.


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