Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Using National Medicare E&M Utilization Data to Drive Coding and Documentation Audits


In emergency medicine billing, evaluation and management (E&M) services are the primary source of revenue. Proper code selection from one level to the next can mean the difference of tens to hundreds of dollars in revenue for each visit depending on the payer. As a result, E&Ms also are a target for audits. Back in 2012, the Office of Inspector General even highlighted emergency medicine E&Ms as a potential source of fraud and abuse in the Medicare program.

One way to ensure proper compliance is to monitor the bell curve of your E&M utilization. Reports released each year by the Centers for Medicare and Medicaid Services (CMS) allow providers to compare their own E&M utilization percentages with national averages in the Medicare program. The most recent figures released are for 2014. See the graph below. (CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.)


However, simply mirroring the Medicare national averages is not necessarily the best way to accurately code E&M services or stay compliant, especially if upcoding or downcoding would be needed to do so.

In a recent Physicians Practice article, “Upcoding vs. Downcoding: Know the Difference,” G. John Verhovshek, MA, CPC, managing editor for AAPC’s publications, argues for treating E&M coding as the complex process it is.

“Not every provider whose billing patterns fall outside the average is engaged in undercoding or overcoding,” he writes. “A number of factors — including the provider’s subspecialties, practice demographics, patient acuity statistics, administrative adjustments and denied claims analysis, and even local public health data — may legitimately affect the provider’s distribution of E&M service levels. For instance, a provider may see a high percentage of patients with chronic health problems, which may skew his billing averages.”

Instead, use the Medicare national averages as a place to start when conducting internal coding audits, particularly for providers or locations that are outliers. Also, use the averages to help support clinical documentation training for clinicians. Are your averages consistently outside of the national averages? Use regular audits to ensure your documentation supports the codes you are billing. If they don’t, use the opportunity to educate providers and coders in proper coding practices.

“The goal of these internal audits is to ensure that documentation guidelines are met and that services, procedures, and diagnoses are supported at the level they are billed,” Verhovshek says.

Over the years, the E&M national average bell curve has started leaning more to the right with a greater percentage of codes in the level 5 and critical care categories (as you can see above). Regardless of which way your curve is leaning (if at all), be sure you have the documentation to back it up.

For more information, review the CMS Evaluation and Management codes by speciality on the CMS website, and read the Physicians Practice article, “Upcoding vs. Downcoding: Know the Difference.”

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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