How does your E&M coding compare to other allergists?

July 23, 2018

 

Have you wondered how your coding for Evaluation and Management (E&M) services compares to other allergists? Medicare publicly reports specialty-specific E&M utilization data, which they typically use to identify outliers who are overcoding. But this data is also useful if you want to know how your coding compares to your peers.

2016 Medicare E&M code usage for allergy/immunology is summarized below. For new patient visits, the most common code used by allergists was a level 4 at almost 57% of the time. Level 3 was the next most common, at nearly 33%. As expected, levels 1 and 2 were infrequently used and level 5 was used more than 8% of the time.

E&M Code
(new patient)
Allergy / Immunology 2016 Medicare UsageAllergy / Immunology 2016 Medicare Utilization % by Code
992012630.2%
992023,4332.1%
9920354,24832.7%
9920494,18456.7%
9920513,8428.3%
Total165,970100.0%

Source: Medicare Part B Physician/Supplier National Data CY2016, E&M Codes for Allergy/Immunology

 

For existing patient visits, level 3 was the most common at 52%, followed by level 4 at almost 38%. Levels 1, 2 and 5 were used infrequently.

E&M Code
(existing patient)
Allergy / Immunology 2016 Medicare UsageAllergy / Immunology 2016 Medicare Utilization % by Code
9921124,2703.0%
9921237,9764.8%
99213414,92651.9%
99214301,20837.7%
9921520,9782.6%
Total799,358100.0%

Source: Medicare Part B Physician/Supplier National Data CY2016, E&M Codes for Allergy/Immunology

 

Kay Tyler, vice-chair of the Practice Management Committee and CEO of Family Allergy & Asthma in Louisville, Kentucky, regularly analyzes Medicare E&M data. “We have been using the CMS data for a number of years and provide this feedback to each physician every year. It is helpful in identifying outliers and opportunities for training. Most physicians won’t know the exact differences in how to code a Level 3, 4, or 5. The coding requirements are very specific, and we use this data to reinforce accuracy.”

You may want to pull your own historical coding data from your practice management system to see how it compares to the average Medicare coding distribution for allergists/immunologists. If you find one of your providers – or your practice in total – is an outlier relative to this data, consider having a certified coder review your charts to make sure you are coding accurately.

Keep in mind, however, that every practice has a different demographic of patients, and your own experience may not be directly comparable to the Medicare average. Also, it’s critical to make sure your documentation supports the coding level for every visit. An Office of Inspector General (OIG) report from 2010 found 55% of claims for E&M services were incorrectly coded and/or lacking documentation. In addition, a total of 26% of claims were incorrectly upcoded. E&M coding has long been an OIG audit target, so make sure you’re coding and documenting correctly to avoid penalties and fines.

The Centers for Medicare & Medicaid Services (CMS) recently proposed major changes to E&M codes beginning in 2019. Among other changes, CMS is proposing to collapse payment for new and established payment office visits, such that new patient office visits (99202-99205) would be paid at $135 and established office visits (99212-99215) would be paid at $93, regardless of level of complexity. ACAAI and AAAAI are working together to develop a joint response to CMS to address the impact of the proposal on allergists.