E&M Utilization Analysis Frank Cohen, MBB, MPA, Director, Analytics Doctors Management LLC, Knoxville, Tenn. Frank Cohen does not have a financial conflict to report at this time. 1
Learning Objectives Identify the importance of E&M utilization Evaluate comparative E&M databases and statistics Examine how to normalize the CMS database - 3 - Facts About E/M Utilization - 4 - E&M services refer to diagnostic/therapeutic management of the patient furnished by healthcare providers E&M Codes account for approximately: 1% of all procedure codes, 18% of frequency reported to Medicare and 28.4% of payments In the 2017 National Physician Fee Schedule Database, there are 14,489 unique procedure codes 160 unique E&M codes $29 billion of $102 billion in total payments 2
Specific Coding Guidelines E&M code levels and rules were influenced by the RBRVS E&M coding is driven by specific guidelines 1995 or 1997 E&M coding is guided by one of three major criteria: Key components (i.e., office and hospital visits) Time (critical care, counseling, discharge, etc.) Age (preventive medicine) Medical Necessity - 5 - Key Components - 6 - History of Present Illness (HPI) Chief Complaint (CC) Review of Systems (ROS) Past, Family, and/or Social History (PFSH) Examination Problem focused Expanded problem focused Detailed Comprehensive Medical Decision Making Straightforward Low complexity Moderate complexity High complexity 3
Key Component Requirements New visits Requires all three key components to be present Codes based on specific algorithm Established visits Requires two of the three key components to be present Codes based on specific algorithm Overall, over 1,500 decision points go into deciding which E&M code to report for a given visit - 7 - - 8 - Top E&M Categories New Office Visits 99201-99205 Established Office Visits 99211-99215 Outpatient Observation 99218-99220 New Hospital Visits 99221-99223 Established Hospital Visits 99231-99233 Inpatient Observation 99234-99236 Discharge Days 99238-99239 Outpatient Consults 99241-99245 New Inpatient Consults 99251-99255 Emergency Department Services 99281-99285 Nursing Home Visits 99304-99310 4
Modeling the Data Analyzed based upon utilization by category and subcategory Comparisons are specialty-specific Comparisons are done on national, state, locality and intraorganizational Improper utilization can result is severe financial, civil and criminal penalties - 9 - CMS Fraud Prevention Strategies CMS Report to Congress; Fraud Prevention System Second Implementation Year, June 2014-10 - 5
The CERT Review process - 11 - CERT randomly selects a sample of claims submitted to Carriers, FIs, and MACs during each reporting period. Request medical records from the health care providers that submitted the claims in the sample. Review the claims in the sample and the associated medical records to see if the claims complied with Medicare coverage, coding, and billing rules, and, if not, assigning errors to the claims. Where medical records were not submitted by the provider, classifying the case as a no documentation claim and counting it as an error. Sending providers overpayment letters/notices or making adjustments for claims that were overpaid or underpaid. Interested Parties RAC Recovery Audit Contractor (including Medicaid) ZPIC Zone Program Integrity Contractor MIC Medicaid Integrity Contractor MAC Medicare Administrative Carrier PSC Program Safeguard Contractor (MIP) OIG Office of the Inspector General DOJ Department of Justice Private payers, as well - 12-6
2017 Improper Payment Rates - 13 - Types of Errors Reported - 14 - No documentation the provider fails to respond to repeated attempts to obtain the medial records in support of the claim. Insufficient documentation the medical documentation submitted does not include pertinent patient facts (e.g. the patient s overall condition, diagnosis, and extent of services performed). Medically unnecessary service claim review staff identify enough documentation in the medical records submitted to make an informed decision that the services billed were not medically necessary based on Medicare coverage policies. Incorrect coding providers submit medical documentation that support a lower or higher code than the code submitted. Other Represents claims that do not fit into any of the other categories (e.g. service not rendered, duplicate payment error, not covered or unallowable service). 7
2015 National Improper Payment Rates by Error Category - 15-2015 National Improper Payment Rates by Error Category - 16-8
Service-Specific Overpayment Rates - 17 - Type of Services with Up-coding Errors Up-coding refers to billing a higher level service or a service with a higher payment than is supported by the medical record documentation. - 18-9
Impact of 1-Level E&M Table K4 provides information on the impact of one-level disagreement between Part B MACs and providers when coding E&M services. - 19 - Service-Specific Underpayment Rates - 20-10
Importance of CERT to Auditors - 21 - Intra-Category Analysis Analytical Models Compares utilization of codes within a specific category or subcategory to control group Inter-Category Analysis Compares utilization of related E&M Code categories and sub categories Global Category Analysis Compares utilization of E&M category as a percent of all E&M codes All comparisons must be specialty-specific - 22-11
Data Requirements Provider productivity report (most recent 12 months) Aggregate for single provider or global analysis Segregated for more in-depth analysis By provider and/or location and/or department Separate out the E/M codes Those requiring key components plus discharge days Comparison/Benchmark Data Part B National Summary Data File Provider/Supplier Procedural Summary File Commercially available - 23 - Intra-Category Analysis Compares utilization of codes within a specific category or sub-category to control group and includes calculations for: Resource Differential Calculates average RVU per category Quantifies under or over coding as relationship to control group Acuity Adjusted Charge Differential Financial analysis of over and under coding compared to complexity of procedures reported - 24-12
- 25 - E/M Intra-category Calculations Table 1 - New Office Visits Current Current Current Current Total Practice National Variance Practice v. Redistributed Code Frequency RVU RVUs Dist. % Dist. % Control Frequency Redist RVUs RVU Differential 99201 2 1.25 2.50 0.88% 0.71% 24.95% 2 2.00 0.50 99202 3 2.13 6.39 1.32% 5.63% -76.51% 13 27.21 (20.82) 99203 13 3.09 40.17 5.73% 28.49% -79.90% 65 199.83 (159.66) 99204 147 4.72 693.84 64.76% 44.42% 45.78% 101 475.96 217.88 99205 62 5.86 363.32 27.31% 20.76% 31.58% 47 276.12 87.20 Totals 227 1,106.22 100.00% 227 981.11 125.11 Table 2 - Established Office Visits New Office Visits Current Variance Current Current Current Current / Current Current Total Practice Current National Practice Variance v. Redistributed ReDist Redist Code Frequency Annual RVU calculated RVUs Gross Dist. Practice % Dist. National % Control Practice v. Frequency Annual Redist Gross RVUs RVU Charge Differential Code 99211 Frequency 93 Fee 0.58 Charges 53.94 Dist. 2.12% % Dist. 4.34% % National -51.17% Frequency 190 Charges 110.47 Differential (56.53) 99212 99201 875 1.2555 108.75 $275 1.98% 0.43% 3.85% 2.07% -48.51% -79.25% 16924 211.22 $1,325 (102.47) $1,050 99213 99202 3,482 64 2.0799 7,207.74 $6,336 79.28% 5.49% 44.58% 10.84% 77.83% -49.35% 1,958 126 4,053.27 $12,510 3,154.47 $6,174 99214 99203 686 702 3.06 148 2,099.16 $103,896 15.62% 60.21% 42.14% 30.08% -62.93% 100.15% 1,851 351 5,663.33 $51,910 (3,564.17) ($51,986) 99215 99204 348 44 4.11 211 180.84 $73,428 1.00% 29.85% 5.09% 34.78% -80.33% -14.18% 224 406 919.34 $85,563 $12,135 (738.50) Totals 99205 4,392 47 269 9,650.43 $12,643 100.00% 4.03% 22.24% -81.87% 4,392 259 10,957.64 $69,749 (1,307.21) $57,106 Totals 1,166 $196,578 100.00% 100.00% 1,166 $221,057 $24,479 1. Record frequency and current RVU ($) value 2. Multiply to calculated total RVUs ($) 3. Create frequency distribution calculation 4. Compare to national distribution 5. Calculate difference (variance) 6. Redistribute the frequency 7. Calculate differences 8. Positive tends towards under-utilization comparison while negative trends towards over-utilization comparison - 26-13
Control Analysis and RVU Exposure - 27 - Simultaneous Analysis of Utilization - 28-14
The Devil is in the Details - 29 - Spike Analysis Spiking on any E&M code within a category can draw attention To determine if a code meets spike criteria: Reported more than 66% of the time for a given category Exceeds 50% variance when compared to peers - 30-15
Inter-Category Utilization Compares utilization ratios of related categories Level of office visits to consults Calculated by dividing total frequency for one category by total frequency for another category Total Established Office Visits = 2,505 Total New Office Visits = 563 EOV to NOV ratio = 4.45 to 1 Values are compared to national averages by specialty National average = 3.0 Variance = 50% ((4.5/3.0) 1) * 100 Means that the practice s ratio is 50% higher than peers - 31 - Example: Inter-Category Utilization Measuring category relationships to total E/M visits helps to create a vector analysis of sorts to pinpoint issues - 32-16
-79.20% -62.70% -41.62% -17.80% 0.00% 21.22% 41.12% 38.90% 91.88% Graphing Inter-Category Variances INTER-CATEGORY VARIANCE 1 2 3 4 5 6 7 8 9-33 - Global Category Comparisons Compares utilization of each category and/or subcategory against national averages Allows a three-dimensional look at utilization More accurate determination of potential utilization problems More efficient use of resources to both identify and treat utilization anomalies - 34-17
Global Category Calculations Requires calculation of ALL E/M visits Includes those not compared here Requires calculation of ALL procedures Normally restricted to those with RVU values Category total is divided by total for all procedures Total new office visits = 563 Total all procedures = 12,344 Ratio of NOV to all procedures = 4.56% Comparisons are made by specialty for national ave. National average = 3.32% Variance = 37.35% ((4.56/3.32) 1) * 100 Means that practice reports NOV as percent of all 37.35% higher than peer groups - 35 - Example: Global Category Analysis Measurement of ratios assists the practice in identifying areas of potential misuse and abuse of specific coding categories and subcategories - 36-18
Graphing Global Category Variances - 37 - E&M as an RVU Risk - 38-19
E&M Codes and Time 1. Most procedure codes with a work RVU have an assessed time 2. Time is reported in minutes 3. Time can be aggregated to estimate work effort 4. Assessed time in excess of 2.5 time FMV (5,000 hours) is considered excessive by OIG and subject to audit - 39 - E&M Can Drive Time Risk - 40-20
The Moral of the Story? Properly coding E&M services is critical for the normal operation and management of most every medical practice Understanding E&M code utilization and being able to apply that to both financial planning and compliance risk is critical to keeping the money you worked so hard to earn - 41 - Continuing Education ACMPE credit for medical practice executives.. 1 ACHE credit for medical practice executives.. 1 CME AMA PRA Category 1 Credits... 1 *CPE credit for certified public accountants (CPAs).. 1.2 CEU credit for generic continuing education.. 1 *CPE CODE: 4 0 4 E M Let the speakers know what you thought! Evaluations will be emailed to you daily. 2018 MGMA. All rights reserved. - 42-21
Thank You. Frank Cohen fcohen@drsmgmt.com 727-322-4232 Doctors Management LLC 10401 Kingston Pike Knoxville, TN 37922 MGMA.ORG 22