Gastroenterology Coding Alert

Where do your gastroenterologists stand when it comes to national trends?

Every GI practice has heard that Medicare auditors look at coding trends and bell curves to find outliers, but it’s hard to know exactly what that means in the scope of your day-to-day operations. Fortunately, there are steps you can take to ensure that your practice is coding accurately, and one such step involves benchmarking.

Check out five tips that can help you institute a strategy to better understand how to benchmark.

Background: In essence, benchmarking creates a standard against which you can compare your own data to historical internal results or industry standards. Once you know whether your practice’s coding trends are healthy, you can keep an eye on them to see whether they go up or down.

1. Know What Benchmarking Involves

When your gastroenterologists take blood pressure or look at lab reports, those are benchmarks that they compare against something else for clinical reasons. For instance, your GI providers know that a pulse of 200 or a blood pressure of 160 over 110 are probably not healthy. The same goes for your practice’s well-being — once you know whether or not your coding and billing practices are healthy, you can keep an eye on them to see whether they improve or decline.

This means you should not only compare your coding trends against other gastroenterologists nationwide, but also benchmark against yourself. For instance, if you change your billing or coding processes, you have no way of knowing whether the new program is more efficient if you don’t benchmark your current information against your old data.

In addition, you should use benchmarks not just as a measure of past performance, but also to set goals for your practice, such as in terms of your revenue or claims success.

2. Use Easily Accessible Data

Although there are a lot of variables that you can use for comparison, you may not know where to start. First, try looking at where the practice’s money is going.

For instance, profit and loss statements can track a number of key metrics, such as your operating expense ratio or overhead ratio, which are the total expenses before provider compensation divided by revenue. The management of expenses is a great indication of overall practice efficiency.

Other things you can evaluate from profit and loss statement are staffing costs. This is typically your highest expense category — track that in relation to revenue. Staff payroll expenses, including wages, payroll taxes, and benefits, often represent somewhere around 25 to 30 percent of practice revenue. Using this result as a jumping off point, it’s often easier to diagnose whether your practice is staffed properly.

3. Determine Your E/M Distribution

Your evaluation and management (E/M) distribution is also important to calculate so you know exactly which codes you’re reporting the most frequently in each category. Of course, if you see that your E/M usage changes quite a bit from one month to the next, you shouldn’t necessarily panic. Maybe your providers saw a lot of patients with GI infections at a certain time of year and reported a lot of high-level codes for their management, and then the next month they saw more patients for G-tube rechecks, which were lower-level. The key is to look for and identify trends over time rather than taking a snapshot of one month and focusing on that.

If you know the coding trends for gastroenterology practices nationally, you can compare your code usage to them. (See “Check This Breakdown of Which Codes Gastroenterologists Are Reporting Nationwide” in this issue for information about national coding trends.)

You should also not read too deeply into differences between your coding curves and other GI physicians’. A practice in Florida may be treating older, sicker patients than a practice in San Francisco, for example, and, therefore, may bill more high-level E/M codes. The key is to ensure that you’re coding accurately at all times.

4. Look at Ratio of Each Code to All E/M Services

Besides comparing intra-category codes (comparing the distribution of new patient codes over all levels as well as the distribution of established patient codes over all of the levels, etc.), your practice should also look at intra-category comparisons, such as established patients to new patients, established patients to initial hospital visits, and initial hospital to subsequent hospital services.

In addition, your practice should look at the ratio of a category code to all E/M services, such as looking at the ratio of new patient visits to all E/M codes, established patient office visits to all E/M codes, initial hospital visits to all E/M codes, and so on.

Multiple reference points are helpful to have when analyzing E/M performance. Bell curves, inter-service, intra-service, and comparison to all E/M services gives the practice four points of reference to fully understand how the practice is doing with E/M coding.

5. Analyze and Educate

If you see trends that indicate that one provider in your practice reports all 99215s and another reports all 99212s, examine why. It’s possible that one GI physician specializes in a more complex subspecialty while the other does office-based procedures, and that explains the differences. However, it’s also possible that one of the physicians is coding inaccurately, and it should be a springboard to examine both providers’ records more accurately and launch a training session for them if warranted.