The first next step is to obtain a report generally referred to as a CPT Productivity Report or CPT Utilization Report for each doctor in the group practice. This report can be printed by most all medical billing software programs. This detailed report provides you with utilization information by CPT code for all of the evaluation and management codes. This report should contain at least twelve months of production. The next step is to complete the following worksheet for each physician.

CPT CODE:                 TIMES DONE               PERCENTAGE
99201                      ____________           _____________
99202                      ____________           _____________
99203                      ____________           _____________
99204                      ____________           _____________
99205                      ____________           _____________
                                     Total                             100%

99211                      ____________            ____________
99212                      ____________            ____________
99213                      ____________            ____________
99214                      ____________            ____________
99215                      ____________            ____________
                                     Total                              100%

99221                      ____________            ____________
99222                      ____________            ____________
99223                      ____________            ____________
                                     Total                              100%

99231                      ____________            ____________
99232                      ____________            ____________
99233                      ____________            ____________
                                    Total                               100%

You can also add the consult codes, ER codes, and critical care codes to the worksheet. If multiple physicians are involved, prepare a worksheet showing each doctor side by side (see sample worksheet below). Once the worksheet is prepared, look for the following: Using a limited number of levels of service It is quite common to find during this analysis that certain practice providers will have the habit of leaning to one particular code for their services. This could serve as a red flag to you in that it could trigger an audit or review of the medical practice by a governmental agency or other third party. In other words, the physician may be upcoding his or her services. In these instances, it is critical that the chart documentation agrees with the billing of these codes.

There are numerous reasons for upcoding. These are the most common ones I find:

1. The physician is not educated on CPT coding;
2. The charge ticket is inadequate; or
3. The physician is upset over what he or she gets paid by insurance companies and decides to make up the difference by upcoding.

Upcoding often occurs due to a lack of knowledge as to what is actually required to document the level of service or when the higher level of visit can be used. It can also be the result of a poorly designed charge ticket (ex. Missing visit codes on the worksheet) Unfortunately, but at least infrequently, it can be greed or the “gaming” the system. This is a serious matter and should be approached with extreme caution. I have very seldom found this to be the case. The significance of this upcoding is the greatly increased risk of a third party audit that could result in significant penalties and repayments. Medical practices cannot and should not tolerate upcoding. If this appears to be the case, you may even want to consider engaging an independent third party to conduct a medical record chart review of these suspected upcoded services.

Downcoding

It is quite common to find a medical practice where there appears to be significant downcoding by the physician or physicians. This could be because the physicians fear a third party audit or because they are not educated on which codes to use. In addition, a fee schedule which the physicians consider to be excessive will also trigger downcoding as the physician attempts to align the cost of the service with their perception of its value. Fee issues and related downcoding are particularly pervasive in small communities where most of the people have smaller income levels. Physicians will also downcode because they know they have done a poor job of documentation. Rather than make the effort to learn how to accurately document their services, they simply select a lower code hoping that this will cover them in case of an audit. This type of downcoding can be a serious threat to a medical practice’s profitability and results in lost revenues. In addition, this type of downcoding eventually will hurt the practice should it ever move into capitation. Since the capitation rates are usually based on prior utilization, downcoding can actually result in a lower capitation amount.

Evaluation and Management Coding Analysis Example

The following worksheet shows a coding comparative for a family practice. All three family practitioners perform the same type of services. Now take a close look at the worksheet and see what you can find. After the worksheet I document some of my own observations. These observations will require further investigation in order to answer the questions. Answers to these questions will either improve practice revenues (downcoding) and determine if the practice is in coding compliance (chart documentation supporting codes billed). The answers might also highlight an overstatement of revenue (upcoding).

ABC Family Practice

Utilization for the Twelve Month Period Ended December 31, 2002

Observations:

1. Why is Dr. Reed recording 54% of his new patient visit new patient visits at code 99202? Is he downcoding? If so, why? Or, are the other doctors upcoding?

2. Are Drs. Tinsley and Lima using new patient code 99203 too much? Does the documentation in the medical record support this level of service? 3. Items 1 and 2 also apply to the established visit services.

3.  Items 1 and 2 also apply to the established visit services.