For most practices, E&M codes represent a significant portion of billings — and, for some practice types like pediatrics and other primary care, E&M codes can approach 100% of billings.  Physicians and non-physician providers are often so sensitive to the risk of down-coding, denial or audit that they develop a bad habit of ‘defensive’ E&M coding — i.e., sticking to the lower range of the codes for virtually every patient.  Far from being an effective defense, though, this type of habitual coding may actually create more audit risk, since it leads to a distribution of codes that is skewed rather than the expected bell-shaped curve.  And, it does so while also leaving thousands of the practice’s dollars on the table!

The end of one year and the beginning of another is the perfect time to analyze your practices E&M coding patterns — and set new habits for the new year.  Run a report for each physician by code for the full year, and you can create a table like this that totals how many times each provider used each code:

code 99201 code 99202 code 99203 code 99204 code 99205 Total
Anderson 12 252 900 12 24 1200
Buford 0 132 996 348 0 1476
Cochrane 12 996 96 0 0 1104
Delaney 0 36 732 432 120 1320
Elliott 12 48 1092 156 24 1332

From this data, you can easily calculate percentage utilizations to get a clearer idea of distribution — and from there create a chart to spotlight any skewed coding:

E&M Distribution Chart

E&M Distribution Chart

E&M Distribution Chart

E&M Distribution Chart

Notice the skewed utilizations of Cochrane, Anderson and Elliott?  It’s unlikely these codes are accurate — especially Cochrane, who appears to be habitually and defensively under-coding.  (Note, also, the addition of the CMS averages to the chart — available from the CMS website.  This is a great double-check to see the typical coding mix based on all practices billing Medicare — and to get a sense if your coding patterns will look odd (or audit-worthy) to the CMS.)

Next step: identify the number of instances of under-coding for each provider and each payer, and multiply by the difference in reimbursement — to get a sense of how much under-coding is costing your practice. The end result will be a powerful incentive for your physicians to pay more attention to coding!

Could you use some help doing these analyses for your practice?  The team at Capko & Company can help you understand your data, and train your billing and practice management staff to repeat the analysis in the future, to ensure you stay on track.  Contact us at our “info” mailbox @capko.com for more information.

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