Use E/M Benchmarking to Assess Your Audit Risk
By Stacy Harper, JD, MHSA, CPC
In the current regulatory environment, physicians are searching for ways to minimize audit exposure. One way to do this is by understanding your use of CPT® codes prone to audit review. For example, Medicare administrative contractors (MACs) frequently review high-level evaluation and management (E/M) services. Providers with high use of targeted E/M codes are more likely to be audited.
Use the OIG Work Plan to Help Determine Targets
The 2013 Office of Inspector General (OIG) Work Plan also includes scrutiny of providers with high cumulative Medicare Part B payments and trends in coding of Evaluation and Management Services—Potentially Inappropriate Payments in 2010 (see HHS OIG Work Plan FY 2013, Part I: Medicare Part A and Part B, Other Providers and Suppliers).
Calculate E/M Coding Benchmarks
The first step in determining a provider’s audit risk is to compare the provider’s utilization of E/M codes against other physicians’ usage in his or her specialty. The Centers for Medicare & Medicaid Services (CMS) publishes Medicare Part B utilization data each year to compare against. Using this data, you can calculate benchmarks, or bell curves, for E/M service usage in your specialty by comparing the number of allowed services for each CPT® code as a percent of the total allowed services for a given E/M subcategory billed by providers in the same specialty.
When the benchmark or bell curve for a specialty has been determined, a physician’s claims for E/M services can be compared to identify deviations from benchmarks.
Review Service Volume
In addition to the service type distribution your physician is billing, the overall volume of services may affect his or her risk of an audit. To see if your physician is at risk, compare his or her total annual revenue to specialty standards. You can find this information through Medical Group Management Association (MGMA) and other professional organizations that gather physician revenue data and publish reports showing revenue by specialty. These reports show revenue for the 25th, 50th, 75th, and 90th percentiles. Providers with revenue in the higher percentiles may be more prone to auditing.
Analyze Your Physicians
Although usage may be outside of revenue and level-of-service averages for a specialty, services may still be appropriately coded. Deviations in utilization may be based on variations in patient mix, sub-specialization, marketed service areas, or increased productivity; however, high usage can also be related to improper coding, inflated documentation, and false claims.
To ensure billing and coding compliance you must understand the accuracy of physician coding. An effective auditing program is central to every corporate compliance plan (see OIG Compliance Program for Individual and Small Group Physician Practices, 65 FR 59434). You can minimize risk and improve compliance by aligning your auditing program to reflect the auditing programs of major payers. For E/M services, this may include periodically focusing your reviews on any high-level codes where the physician’s usage is above the “bell curve.”
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