Orthopedic Coding Alert

Because U.S. Office of Inspector General (OIG) investigators review code utilization data also called "benchmarking" you should beat them to it by comparing your code usage to national averages and identify any problem areas.

"Just like HMOs, Medicare reviews coding practices and looks for disparities or red flags, such as physicians whose visits are consistently at the higher levels of coding," says Gary Meza, chief executive officer of Advanced Orthopaedic Centers, an 11-orthopedist practice in Richmond, Va. "Conversely, those physicians who are undercoding to stay on the safe or conservative side could be losing a significant amount of legitimate revenue."

According to Frank Cohen, senior analyst at Medical Information Technology Systems, a national healthcare consulting firm, and author of The E/M Bell Curve, not all benchmarking is beneficial to your practice. For instance, if you try to benchmark your practice's use of a specific procedure code, such as arthroscopic medial meniscec-tomies (29881), the actual numbers depend on your population base. "If you're in an older population base, the chances of your doing a lot of those surgeries is much lower than if you're in a younger population base. So benchmarking, unfortunately, may not be an exact science because it cannot take into account all the idiosyncrasies in the population base."

Consequently, most consultants recommend performing an E/M comparison study because all orthopedists perform at least some type of E/M services. CMS lists the raw data on its Web site from which you can filter out the information for orthopedic surgery and calculate percentages. We have compiled this information for the most commonly billed E/M codes, listed at right.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, recommends using this data in three ways:

1. Review Data Across Categories. For instance, Sandham suggests, determine the relationship between outpatient consultations (99241-99245) and new patient office visits (99201-99205), then compare that to the national averages using the CMS database. If you are billing more consults than new office visits, your practice may be confusing referrals with consultations.

The point here isn't to suddenly start billing all of your consults using new patient codes, Sandham says, but to provoke orthopedic practices to review records to ensure that the charts are being coded correctly.

2. Review Data Within Categories. For example, compare your range of established office visit codes to Medicare's. Although your practice may bill mainly 99212s, CMS suggests that the average orthopedic practice bills more 99213s. This should inspire you to determine whether you routinely undercodes claims.

3. Review Data Per Code. For instance, compare your practice's use of 99214 against the Medicare national orthopedic averages.

Sandham warns practices not to change their coding practices just to stay within the averages. "If you have a higher utilization profile, you may be treating sicker patients." For instance, an orthopedic oncologist would probably bill more high-level E/M codes (such as 99214 and 99215) than someone who only treats fractures.

And, Cohen says, the Medicare statistics are drawn from unaudited data, so not every code included was assigned correctly to the patient's service. Also, the CMS data is all Medicare, and your practice probably is not. (To learn how to normalize your practice's utilization against the CMS data, which is 100 percent Medicare, see our sidebar, Compare Apples to Apples, at right.)

Some practices choose to benchmark against similar practices in their area, but Cohen does not recommend it.

For instance, he suggests, the Smithtown Orthopedic Association decides to compare E/M utilization averages among its member practices. "First of all, one practice may treat mainly athletes, while another does mostly hip replacements. So they won't be performing the same procedures and, therefore, comparing the number of a certain procedure performed will not be accurate."

In addition, this type of comparison assumes that both practices are coding properly. "If you only bill 200 99215s a month and another local orthopedist bills 500, that doesn't mean you should start upcoding claims," Cohen advises. "If that practice is coding incorrectly, the entire model is skewed and can actually cause the OIG to look even more closely at your practice because they may say, 'Everyone in Smithtown is overbilling, let's look more closely at them.' "

The best advice for benchmarking is to compare your practice's code use for one time period against your data for another period, Cohen says. For instance, compare your data from January through June to your statistics from July through December. This way, you can determine code use across the board E/M codes as well as surgical. If the comparison shows a big change in the way your practice billed, look further to determine why. You may be coding more accurately now, or vice-versa. Keep an eye on compliance when comparing annual utilization statistics so you aren't tempted to say, "We billed more high-level codes last year, so let's code more of them this year."

Sandham also recommends comparing physicians' utilization individually: "Compare each physician in the practice to the group as a whole, then to CMS. Even though you may be on track with CMS' data, you may find that one physician in your practice is billing too high and another is billing too low this would put you on average in the middle, but it doesn't mean that the physicians are correctly coding."