Code your way to better reimbursement

October 19, 2007

Want to give yourself a nice raise that third-party payers won't? Improve your coding.

Key Points

Many doctors surrender thousands of hard-earned dollarseach year through coding missteps they could easilyavoid. The errors and omissions don’t amount to muchindividually. But multiplied over a year, the losses can easily reachfive figures.

To make matters worse, doctors who know all the rules sometimes shortchange themselves intentionally for fear of being seen as Medicare cheats. Cincinnati coding consultant Maxine Lewis knows of one large surgical group that lost more than $1 million a year in revenue because the surgeons routinely coded bona fide consultations as lower-paying new-patient visits. Ironically, such attempts to play it safe often attract the attention of the government auditors whose suspicions the undercoding was meant to dispel.

Conduct a coding analysis

These 40 codes are the ones you should focus on. While E&M codes will invariably dominate the CPT list, other high-ranking codes will be specialty-specific: flu vaccines (90658) for internists and FPs, for instance, and fetal ultrasounds (76805) for obstetricians.

Next, break down your E&M coding by category and level of service. This will tell you, among other things, what percentage of established-patient visits falls into each of the 99211-99215 levels. Then compare your coding profile with that of your specialty peers nationwide to determine if you're an outlier in a particular level. You can do that by creating a national profile with coding data from Medicare (visit and search for "Medicare Utilization for Part B"), but you'll need to plug the numbers into a spreadsheet. An easier route is to buy the 2007 E/M Bell Curve Data Book from a company called DecisionHealth, which has already analyzed the Medicare numbers, or to hire a coding consultant who has such a book.

Keep in mind, though, that Medicare bell curves aren't prescriptive, says Betsy Nicoletti, author of The Field Guide to Physician Coding. You may be justified in coding more 99214s than the norm, for example, if you specialize in geriatrics and most of your patients have multiple chronic conditions. But a dramatic divergence from the norm should prompt you to question your coding, says Nicoletti.

Finally, examine your charge ticket. This form should list your most frequently used CPT and diagnostic codes. A charge ticket that omits such everyday codes can be costly: It forces you to write in missing numbers, thereby inviting an error and an insurance-company denial. Or you may forget to use the omitted codes and miss out on reimbursement.

While you're at it, look for-and correct-other charge ticket flaws. Does it list all levels of E&M codes? Omitting 99221 and even 99212 from the series for established office visits, as some physicians do, suggests a bias toward charging for higher levels and may arouse suspicion. The superbill should also include preventive medicine E&M codes, to demonstrate that you don't routinely code physicals as established-patient office visits for the sake of higher reimbursement.