Wiki Percentage distribution for E/M levels

Lake Worth, FL
Best answers
Please help!!

My boss and his bosses are telling me that the percentage for level 4's both new and established patient should be at 80% for urgent care centers. AAPC has a E/M benchmarking tool where you can enter your number of visits for each level and it will tell you what your percentage is and compare it to what CMS suggests. You are able to select your specialty as well so that the data is relevant. Problem is, there is not selection for urgent care. I always use the Family Practice selection since we are actually both. Does anyone know how I can find the data to show my superiors that 80% is too high? Or am I wrong?
I fundamentally disagree with having a 80% 99204/992014 requirement of all visits. Firstly, providers should always only code what is medically appropriate. I understand the idea of having a national benchmark on how other providers are generally are doing, but I see the 80% of 99204 as inflated. This will likely trigger external audit from CMS and Health Plans. The documentation requirements for a 99204 are pretty high, especially for a "quick" Urgent Care visit. If your providers are basis the code level on time, then the question begs if the provider is truly spending "Greater than 50% face to face" with the patient? I see this "80%" practice as very risky and more driven by upper management than the providers.

Regarding the E/M Utilization Benchmark tool, I think you can use Family Practice for Urgent Care Centers. UC is not like Emergency Rooms, and is more of an extension of FP services on a more per diem basis.

Hope this is helpful, let me know if you need references from OIG.
I could not agree more! Providers should only be documenting what is medically necessary, thus billing what is appropriate according to what is documented. And, yes, this is coming from upper management.

If I could have references from OIG that would be super helpful! I searched and searched for some concrete info on here, OIG and CMS and I must be overlooking it. I am not sure if I am just looking for the wrong thing or what.

Thank you for your response!