Why Medicare wants to compare your coding to other doctors

Q: I received a letter from Medicare stating that I had more 99214s than my cohort of internal medicine providers, and that I needed to correct this in six months. I don’t believe that I’ve done anything wrong. How can they do this?

A: The chances are good that you haven’t done anything wrong at all. In fact, you may have done something right.

Medicare administrative contractors (MACs) through the Centers for Medicare & Medicaid Services (CMS) are fond of comparing individual provider evaluation and management (EM) code profiles to the national, regional or contractor profile for that provider specialty. In other words, they compare your billing codes to your peers’ billing codes.

If you fall out of the normal distribution and become an outlier it is not uncommon to receive a letter suggesting that you look more like everyone else. The fact is however, that since so many providers under-code these services--perhaps due partly to these types of suggestions--that if you are an outlier, you may be coding more accurately than some of your peers.

There are no frequency limitations on the basic EM codes, at any level. The codes are to be billed at a level commensurate with the work performed or the time spent, if that applies. If your codes are supported by the documentation and support medical necessity:

they are the correct codes and it doesn’t matter whether you bill more of them, or more often, than anyone else.

It is true that if you continue to have an outlier profile you could easily be the recipient of an audit for the codes or claims in question. And it is equally true that if you had the correct codes to begin with, and decent documentation, then the audit will reveal that as well.

There is a lot of fear surrounding CMS review activity, but nothing dispels it quicker than a positive review. There has been a national initiative on reviewing 99214s during the last year. Chances are this is what they are monitoring. Given that you are an internal medicine provider, then a high percentage of 99214 for a Medicare population shouldn’t surprise anyone. In fact, Medicare has been known to say that they expect that most follow-up visits would be of the level 4 variety. 

That can be as simple as your 90-day surveillance of diabetes, hypertension and hyperlipidemia. Remember too that a stable chronic and a worsening chronic is also moderate decision-making, and a new problem with a differential that you work up. A 99214 is rather common, easy to document, and you should have nothing to worry about if you document even reasonably well.

If you are a provider that uses the electronic health record to make 99213s look like 99214s with buffed history and over-sized exams, or ignores the concept of medical necessity, then you may have more interaction than you’d like.