Coding Compliance

Module 05 Assignment – Coding Compliance: Analyze, Investigate, and Take Action

In this assignment, you will take on the role of a Coding Manager who has been summoned to the Chief Medical Officer’s (CMO) office. The CMO has expressed a concern about the coding for Internal Medicine (IM) physicians because she has received some complaints. Some IM doctors indicate that pay amongst the IM doctors is varying a great deal, and they want to make more money, as well.

Since physician pay is driven by Evaluation and Management (E&M) coding assignment, the CMO wonders if the coder is new. You explain that there are several coders in the IM area since coders are cross trained over many specialties for vacation coverage. You indicate that you will track 100 accounts for each of the nine (9) IM providers and will use the national comparative data to identify possible coding problems.

Your analysis will require you to:

 Part I: interpret data that has been collected

 Part II: manipulate the data

 Part III: determine if you need to make changes to your coding staff and report back to the CMO

Part I – Interpret the Data

Chart 1: Here is the national comparative data for physician E&M level assignment.

Source: Medicare Provider Utilization and Cost Physician and Other Supplier NPI Aggregate, 2013.The detailed NPI and HCPCS data file can also be used to examine how patterns of service use vary across physicians and specialties. Chart shows the distribution of routine office visits (a.k.a., Evaluation and Management services) for some common specialty types. Medicare has five different HCPCS billing codes (99211-99215) for routine office visits based on the length of the visit ranging 5 minutes for 99211 (level 1) to 40 minutes for 99215 (level 5). As may be expected, specialties such as Dermatology bill a higher proportion of shorter-length office visits (e.g., level 2) than Internal Medicine or Nurse Practitioners, whereas specialties such as Cardiology and Hematology/Oncology bill a higher proportion of higher-length office visits (e.g., levels 4 and 5).

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100%

Internal Medicine Cardiology Nurse Practitioner Opthalmology Dermatology Hematology/ Oncology

E&M Level Assignment, Provider Type

99211 99212 99213 99214 99215

The following questions use the information provided above.

1. Which Specialty type averaged 28% of E&M level 99212? a. Cardiology b. Internal Medicine c. Dermatology d. Ophthalmology

2. Which Specialty type has the highest average in E&M level 99215? a. Hematology/Oncology b. Cardiology c. Dermatology d. Ophthalmology

3. Which E&M level has a routine office visit with a length of visit equal to 40 minutes? a. 99214 b. 99215 c. 99213 d. 99212

Chart 2: Further comparative data includes the typical reimbursement for each level.

E&M Level Average Reimbursement

Internal Medicine Breakdown from

Chart 1 Level 99211 $18.46 3%

Level 99212 $38.03 3%

Level 99213 $64.27 44%

Level 99214 $96.61 46%

Level 99215 $130.40 4%

100%

4. What is the difference in payment between the highest E&M level and the lowest E&M level? a. $130.40 b. $92.37 c. $110.06 d. $111.94

5. What E&M level is most frequently assigned to an Internal Medicine account according to the National Comparative Data?

a. 99211 b. 99215 c. 99214 d. 99212

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To complete the data tracking, you randomly select 100 accounts for the month for all internal medicine providers and record the billed E&M level for each account. The IM providers are doctors: Viper, Shaniff, Marck, Patel, Chobinson, Abraham, Raju, Myers and Turner. Your findings regarding the 900 accounts is recorded below.

Chart 3: Total Number of Accounts by Provider for each E&M Level.

Level Assigned Viper Shaniff Marck Patel Chobinson Abraham Raju Myers Turner

Level 99211 2 8 22 4 0 5 6 1 0

Level 99212 15 10 33 17 7 25 8 18 0

Level 99213 41 39 35 41 80 37 29 31 2

Level 99214 26 41 10 34 11 27 36 36 40

Level 99215 16 2 0 4 2 6 21 14 58

100 100 100 100 100 100 100 100 100

6. Which provider in Chart 3 has the most accounts in the highest E&M level? a. Viper b. Chobinson c. Myers d. Turner

7. From Chart 3, which provider’s data seems to reflect downcoding? a. Chobinson b. Viper c. Marck d. Myers

8. From Chart 3, which provider’s data seems to reflect upcoding? a. Turner b. Raju c. Shaniff d. Abraham

9. From Chart 3, which provider’s data seems to reflect clustering? a. Chobinson b. Turner c. Raju d. Patel

10. From the above 900 accounts, which providers seem to have possible coding compliance issues that you should follow up on?

a. Myers, Raju and Patel b. Patel, Chobinson and Shaniff c. Abraham, Raju and Marck d. Turner, Marck and Chobinson

11. Using data from Chart 2 and Chart 3, forecast which provider would likely have the highest income and then which provider would likely have the lowest income for these 900 accounts.

a. Chobinson and Abraham b. Turner and Marck c. Patel and Shaniff d. Raju and Viper

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Part II – Manipulate the Data

Chart 4: Total Number of Accounts by Provider for each E&M Level with Average Reimbursement.

All Providers, Clinic Total for Month Level Assigned

Average $ Reimbursement Viper Shaniff Marck Patel Chobinson Abraham Raju Myers Turner

Level 99211

$18.46 2 8 22 4 0 5 6 1 0

Level 99212

$38.03 15 10 33 17 7 25 8 18 0

Level 99213

$64.27 41 39 35 41 80 37 29 31 2

Level 99214

$96.61 26 41 10 34 11 27 36 36 40

Level 99215

$130.40 16 2 0 4 2 6 21 14 58

100 100 100 100 100 100 100 100 100

12. Complete the last two columns on Charts 5 and 6 below for the 2 providers you identified in question #11 above. To calculate column 4, use equation (Avg. Reimbursement) x (# Accounts) = Income. Then add the numbers in the 4th column to calculate the total income for the provider for these accounts. (Charts 5 and 6 each need a Provider NAME plus 11 numbers to be complete.)

Chart 5

Provider Name:

Office Level

Average Reimbursement

Provider Accounts from Chart 2

Income for this Level

99211 $18.46

99212 $38.03

99213 $64.27

99214 $96.61

99215 $130.40

Total Provider Income for these Accounts =

Chart 6 Provider Name:

Office Level

Average Reimbursement

Provider Numbers from Chart 2

Income for this Level

99211 $18.46

99212 $38.03

99213 $64.27

99214 $96.61

99215 $130.40

Total Provider Income for these Accounts=

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13. Which provider has the highest income of all 9 providers in Internal Medicine? a. Myers b. Marck c. Chobinson d. Turner

Part III – Determine if you need to make Coding Staff changes

Meet the Coders

Grace: A credentialed coder who has been coding for 18 years and specializes in orthopedic coding. As a result, she often gets emails from newer coders when they are faced with a challenging ortho account. She is happy to help, pleasant to work with, has excellent attendance and has above average coding accuracy.

Codes for:

 Orthopedic providers – Gunderson, Talia

 Podiatry providers – Borchart, Riggins

 IM Providers – Raju, Patel and Shaniff

Penny: A credentialed coder who has been coding for 4 years. She has an associates degree which has benefited her because she is often able to help with anatomy questions from other coders. She is a quiet coder who struggles with attendance and maintains average coding accuracy.

Codes for:

 Surgery providers – Maxwell, Chandra

 IM Providers – Turner, Marck, Abraham

 Cardiology providers – Wyatt, S. Khan

Hiba: A credentialed coder who joined the coding team 5 months ago and is nearing her probationary evaluation review. Her coding accuracy has been very good on each of her monthly reviews to date. She has not had any unscheduled absences.

Codes for:

 Family Practice provider – Zhionobi

 IM Provider – Chobinson, Myers

 Surgery provider – Mendez

14. After reviewing the above coding assignments and the information in Charts 1 through 5, which coder reflects top notch coding performance?

a. Hiba b. Grace c. Penny d. Hiba, Grace and Penny

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You meet with Penny and you learn that Dr. Turner called her two months ago and complained about his level assignments. He invited her to lunch, and they have been lunching each week since then. You decide to do a documentation and coding audit on the Dr. Turner accounts tracked above. To do so, you review the documentation on each account and then you assign an E&M code to each account. This allows a comparison between your E&M coding assignments and Penny’s E&M coding assignments. Your findings are below: Chart 7 Provider Name: Turner

Office Level

Penny’s Assigned

Levels

Your Assigned

Levels

99211 0 4

99212 0 15

99213 2 38

99214 40 41

99215 58 2

15. In reviewing the coding disparity in Penny’s coding of Dr. Turner’s accounts, you report the following to the CMO:

a. A coding compliance issue has been identified and will be monitored every week until an improvement is evidenced or another action becomes necessary.

b. Coding is accurate and compliant for all Internal Medicine providers and thank her for the input from the CMO.

c. There is a coding compliance issue for surgery providers and coding assignments are going to be changed to correct it.

d. There are no findings to report and a coding consultant will be brought in from the outside to investigate coding compliance.

1. Provider Name (Chart 5):
2. Provider Name (Chart 6):
3. Chart 5: Provider Accounts from Chart 2 – 99211:
4. Chart 5: Provider Accounts from Chart 2 – 99212:
5. Chart 5: Income for this Level – 99212:
6. Chart 5: Provider Accounts from Chart 2 – 99213:
7. Chart 5: Income for this Level – 99213:
8. Chart 5: Provider Accounts from Chart 2 – 99214:
9. Chart 5: Income for this Level – 99214:
10. Chart 5: Provider Accounts from Chart 2 – 99215:
11. Chart 5: Income for this Level – 99215:
12. Chart 5: Total Provider Income for these Accounts:
13. Chart 6: Provider Numbers from Chart 2 – 99212:
14. Chart 6: Provider Numbers from Chart 2 – 99213:
15. Chart 6: Provider Numbers from Chart 2 – 99211:
16. Chart 6: Provider Numbers from Chart 2 – 99214:
17. Chart 6: Provider Numbers from Chart 2 – 99215:
18. Chart 5: Income for this Level – 99211:
19. Chart 6: Income for this Level – 99211:
20. Chart 6: Income for this Level – 99212:
21. Chart 6: Income for this Level – 99213:
22. Chart 6: Income for this Level – 99214:
23. Chart 6: Income for this Level – 99215:
24. Chart 6: Total Provider Income for these Accounts:
25. Group1:
26. Group2:
27. Group3:
28. Group4:
29. Group5:
30. Group6:
31. Group7:
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33. Group9:
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35. Group11:
36. Group13:
37. Group14:
38. Group15: