| E/M Utilization Benchmarking Calculator | |
| E/M benchmarks are based on charges for services submitted to Medicare from January thru December 31, 2004. The data shows by specialty how physicians are using E/M codes. E/M coding is expected to range as a bell-shape curve. If physicians are billing outside the expected use of E/M codes, there is some risk of audit. Code submissions and billing patterns are compared to peers in the same specialty and locality. Keep in mind that this data includes E/M codes billed but no evaluation was made to verify if documentation necessarily supported these code choices. Therefore, do not use the data to justify code choices; only proper documentation can justify coding. Also, you may wish to seek utilization data based on your state for comparison. Your state utilization data may differ from the national data used in this tool. (Contact your state medical association or coding and reimbursement consultant to see if state data is available.) Specialties for comparison with this tool include: GP, S, AL, OTO, C, D, FP, GE, IM, N, NS, OB/GYN, OPH, ORS, P, PUL, U, PD, HEO. |
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| How to use the E/M Benchmarking Calculator | |
| First, make a copy of this Excel document for inserting your data. | |
| A. | Enter the name of your practice, the name of the provider in which the benchmarking comparison is being made, and the date (period of time that productivity figures were gathered.) |
| B. | Gather productivity data on your practice by generating a computer software report that gives the totals on each E/M procedure code that was billed for a certain period of time. |
| C. | Enter these numbers in the column 1 titled, "Your Practice Productivity" |
| Example: If a physician billed 99201 office visit 785 times, enter this figure under column 1 titled, "Your Practice Productivity" next to the code 99201. Do this for each CPT code listed under "E&M Codes." | |
| D. | Column 3 titled,"CMS Data on Average Code usage within Category" is a set benchmark percentage. |
| E. | After entering your numbers by provider, an automatic calculation will show under the column 2 titled, "Your Practice Code Usage within Category." |
| F. | Also automatically calculated is column 4 titled, "Difference in Provider Code Usage Compared to CMS Code Usage" |
| G. | You can prepare a report for each provider. Make sure the benchmark data represents the specialty of the provider. |
| CPT Codes © 2007 American Medical Association © 2007 Practice Support Resources, Inc. | |
| Practice Name: | Provider: | Date: | ||||
| General Practice | 1 Your Practice Productivity |
2 Your Practice Code Usage within Category | 3 CMS Data on Average Code Usage within Category | 4 Difference in Provider Code Usage compared to CMS Code Usage | ||
| 99201 - Office visit, new patient | 50 | 5.00% | 2.20% | -2.80% | ||
| 99202 - Office visit, new patient | 280 | 28.00% | 17.17% | -10.83% | ||
| 99203 - Office visit, new patient | 420 | 42.00% | 38.31% | -3.69% | ||
| 99204 - Office visit, new patient | 200 | 20.00% | 32.23% | 12.23% | ||
| 99205 - Office visit, new patient | 50 | 5.00% | 10.08% | 5.08% | ||
| 99201- | 1,000 | |||||
| 99211 - Office visit, established patient | 0.00% | 3.18% | 3.18% | |||
| 99212 - Office visit, established patient | 210 | 7.00% | 11.95% | 4.95% | ||
| 99213 - Office visit, established patient | 1,870 | 62.33% | 60.86% | -1.47% | ||
| 99214 - Office visit, established patient | 760 | 25.33% | 21.33% | -4.00% | ||
| 99215 - Office visit, established patient | 160 | 5.33% | 2.67% | -2.66% | ||
| 99211- | 3,000 | |||||
| 99217 - Observation care discharge | 100.00% | |||||
| 99217- | 0 | |||||
| 99218 - Initial observation care | 23.60% | |||||
| 99219 - Initial observation care | 44.20% | |||||
| 99220 - Initial observation care | 32.20% | |||||
| 99218- | 0 | |||||
| 99221 - Initial hospital care | 7.44% | |||||
| 99222 - Initial hospital care | 44.06% | |||||
| 99223 - Initial hospital care | 48.50% | |||||
| 99221- | 0 | |||||
| 99231 - Subsequent hospital care | 27.15% | |||||
| 99232 - Subsequent hospital care | 53.97% | |||||
| 99233 - Subsequent hospital care | 18.88% | |||||
| 99231- | 0 | |||||
| 99234 - Observation/hospital, same date | 25.62% | |||||
| 99235 - Observation/hospital, same date | 49.79% | |||||
| 99236 - Observation/hospital, same date | 24.59% | |||||
| 99234- | 0 | |||||
| 99238 - Hospital discharge day | 79.62% | |||||
| 99239 - Hospital discharge day | 20.38% | |||||
| 99238- | 0 | |||||
| 99241 - Office consultation | 4.36% | |||||
| 99242 - Office consultation | 14.78% | |||||
| 99243 - Office consultation | 36.65% | |||||
| 99244 - Office consultation | 32.12% | |||||
| 99245 - Office consultation | 12.09% | |||||
| 99241- | 0 | |||||