As you are aware, your most common pediatric visits—your sick visits— are supposed to be distributed in a bell-shaped curve. The codes that correspond to those visits—99211 through 99215—should also follow that pattern as a general rule. It is an accepted fact that coding outside of "the curve" will lead to more chart audits and reimbursement denials. Staying within the curve, therefore, has always had practice management benefits in addition to ensuring a certain level of clinical consistency.
Pediatricians are generally 99213-centric. That is, you are much more likely to code your sick visits with a 99213 code rather than the 99214 or 99215 experts suggest reflect the true nature of the visit.
Has it ever occurred to you that your coding pattern might cost you money? A lot of money? Up to $45,000 a year, on average, in fact?
Before we examine what is actually happening in your practice, we have to look at what "should" be happening. According to the AMA, HCFA/CMS, and other coding experts, your bell curve of Established Office Visits should look something like this:
Depending on which source you use, you'll get a range of possible "ideal" curves, but they approximate the examples above. For the purposes of this discussion, let's presume a 5%-12.5%-65%-12.5%-5% split, although the MGMA found that pediatricians have a curve that looks more like this:
With all due respect to the MGMA, we think the curve for pediatricians is even steeper. Our experience, which is considerably more extensive than the MGMA sample when it comes to pediatrics, indicates that pediatric coding distribution looks more like this:
Can you see where this is heading? It would appear that the 99213-centricity of your coding patterns implies that of your 1000s of 99213 visits every year, some, perhaps, should be 99212s. More importantly, though, many of them should be 99214s. And, from the look of your patterns, more of your procedures should become 99214s than 99212s.
Again, how do we know this? The "expected" percentage of 99213s, for a typical practice, is in the 60-70% range, while most pediatric practices are in the 70-80% (or more!) range. And, if you check out the dozens of code distribution articles posted online, you'll see that Pediatricians are routinely at the top of the "99213-centric" pile.
Here's the kicker. If you're coding and charting properly, you will benefit from the fact that 99214s are worth more than twice a 99212. So, even if adjusting your curve means utilizing the 99212 code more often...the additional 99214s more than make up the difference.
"Wait," you say. "I can't just code my visits any-which-way." No, of course you can't. You need to make sure that each and every one of your visits is properly documented.
However, is it safe to say that, perhaps, you had at least one 99213-coded visit today that could have been a 99214 if you'd simply recorded a little more information in the chart or asked about another system? If you're like most pediatricians, the answer is "Definitely." And, to be careful, it's probably safe to say that you've coded a 99213 on a visit that didn't fulfill the E/M standards (there are enough of you out there who code 99213s 95% of the time that that we can say this unequivocally).
Let's look at this another way. How often have you checked off the "99213" box on the encounter form before you actually performed the visit, if only in your mind?
Presuming that you can be convinced that your coding distribution might not be up to snuff, would you like to see what coding properly will do for you?
By using the calculator below, we will simply redistribute your codes to meet a more appropriate distribution of your choosing. If 85% of your codes are 99213s now, how it would affect your bottom line if you did "only" 75% instead and moved those extra procedures into 99212s and 99214s?
PCC tossed in some sample numbers that represent an "average" pediatric practice and used it for our instruction sample below. While your practice is likely to be quite different in terms of size or distribution, you should see that the difference is quite large!
That's it. (PCC customers, of course, can do this in seconds.)
The results should be easy to follow: