Part B Insider (Multispecialty) Coding Alert

Published on Fri May 23, 2003 PDF

If you're concerned that you may be downcoding, then it's important to have a certified coder audit some of your charts, says Edward F. Babb, MD, CPC, with Physician Advocate Consultants & Trainers in Lafayette, N.J. The first step is to bring in an outside party to look at charts and see if the office is coding and documenting properly.

Match the CPT Codes you submitted with the documentation on file, urges Alice Gosfield with Alice G. Gosfield and Associates in Philadelphia. "Practices should do that anyway as a matter of compliance for upcoding, downcoding and documentation generally," she insists.

'Why Am I an Outlier?'

Another approach is to plot a chart showing the evaluation and management reporting levels by each physician and see if the coding falls into a "nice bell-shaped curve," says Ronald Evans, executive director of South Texas Cardiothoracic and Vascular Surgery in San Antonio. If the E/M coding falls too far outside the bell curve, then "the physician has to ask the question, 'Why am I an outlier?'"

The "bell-curve" technique catches both upcoding and downcoding, Evans notes. If it turns out that most of the claims are clustered among the lower codes, then he recommends an in-depth audit of the physician's charts. If there's no other factor, such as patient mix complexity, pushing the codes downward, then you need to drill down and figure out why the physician is coding a particular patient as level two rather than level three, Evans says.

But what if a physician's claims all fall neatly into a bell curve, but in fact that physician is seeing a large number of higher-acuity patients? The physician in question may be downcoding them to stay within the bell curve.

The only way to detect this is to plot that physician's billings from year to year. "Has there been a shift downward in their coding from time to time?" Evans asks. If so, then ask that doctor, "What happened in 2001 that caused you all of a sudden to start coding differently?"