Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 02, 2010 PDF

Follow the benchmarking guidelines to use this data responsibly.

Now that you've read the specifics about benchmarking (see page 209 for more details and guidance), it's time to look at the CMS data.

The most recent utilization statistics that CMS has posted on its Web site are from 2008, with information provided for each specialty. Depending on your practice's specialty, you can create your own spreadsheet of information that's tailored to your patient base using Medicare's specialty specific utilization data, available at the link below. For general educational purposes, we've provided a breakdown that spans all specialties. Here's how Medicare practitioners used the office visit E/M codes in calendar year 2008:

Check out Most Frequently-Billed Codes

In all, Medicare paid practitioners for 221,128,116 million office visits (99201-99215) in 2008. Nationally, 99203 and 99213 were the codes all specialties billed most frequently for new patient and established patient visits, respectively.

Look at the allowed services for each office visit code as a percentage of the total, and compare them with your own practice's data:

Documentation Must Justify E/M Level

At every E/M level, you have to be able to document appropriately to support your coding choice.

For instance: To report 99214, you must document at least  two of the following: a detailed history, a detailed exam, and medical decision-making (MDM) of moderate complexity. You also need to be sure that the nature of the presenting problem and medical necessity support coding a level four. Many coding consultants recommend not selecting an established patient E/M code level above that supported by the MDM level.

Pitfall: Some insurers raise red flags when a practice only  reports 99213 for established patient E/M services. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that level.

Bottom line: Choose the E/M code based on the documentation and medical necessity every time, and your coding will naturally reflect the practitioner's range of services.