The Upward Trend of the E&M Bell Curves Continues - Analysis Tips for Physician Employers


Based on a review of Medicare Part B data, physicians are using more moderate/high-level evaluation and management (E/M) codes over time. BFMV reviewed physician utilization data posted on the CMS website. Taking all specialties together as a whole indicates a noticeable shift toward codes with moderate levels of medical decision-making (the 5 possible options being: straightforward (with problem-focused history), straightforward (with expanded problem focus), low, moderate, or high). As shown in the graph, this is most apparent in the move from 99213 to 99214 codes for established patient visits and from 99202 to 99204 for new patient visits.


This is not a new trend. In 2012, the OIG issued the results of a study showing that between 2001 and 2010, physicians increased their billing of higher level (i.e., more complex and expensive) E/M codes in all 15 visit types. The CMS deletion of codes 99201 and 99211 (effective in 2021) will no doubt offer additional interesting observations in consideration of these trends.


In light of the shifts we are seeing, here are a few steps that physician employers can take to assess and reduce compliance risk.


1. Run distribution analyses on physician E/M codes. Compare the results to other physicians in the same specialty. (Data can be downloaded from the CMS website.)


2. Given the OIG's interest in how coding practices have changed over time, compare physician distributions to current CMS data as well as to CMS data from several years back. (Data back to 2009 is available on the CMS website. The 2012 OIG study also provides a look at 2001 data.)


3. Compare physician Work RVUs to external benchmarks like the MGMA survey as well as to internal benchmarks. If Work RVUs look unusually high or low, confirm that there isn’t a coding issue and that the Work RVUs are being calculated properly.


4. Compare physician E/M coding distributions over time. Is there evidence that coding habits have changed?


5. Pay attention to the recommendations that the OIG had for CMS in the 2012 study: 1) continue to educate physicians on proper billing for E/M services; 2) review physicians' billing for E/M services; and 3) review physicians who bill higher level E/M codes for appropriate action.


Contact us for assistance in performing these analyses.


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