Fam Pract Manag. 2011 Sep-Oct;18(5):12.

Finding the right balance of 99214s

Your recent article “Five Common Coding Mistakes That Are Costing You” [March/April 2011, ] highlighted that family physicians are often failing to code potential 99214s. However, at the same time, we are getting notices from Medicare stating that physicians should watch their ratios of 99214s to avoid audits. This is a tough balance. Can you tell me what percentage of our office visits can be 99214s without raising a red flag? We have an EHR and try to code very responsibly and accurately, but the idea of a government audit is scaring us.

Author's response:

Medicare has not established a percentage of 99214 visits that would automatically trigger an audit. Like other payers, Medicare contractors expect the distribution of evaluation and management (E/M) codes to resemble a bell-shaped curve. Payers recognize there may be some left or right shift to the curve based on specialty, patient population and other practice-specific factors. They compare an individual physician's coding patterns to those of other physicians in the same specialty and geographic area. Those physicians who are outside the norm may be subject to a review.

The coding frequency comparison spreadsheet referenced in the article you mention allows you to compare your personal coding pattern to those of other family physicians in much the same way that Medicare would, using benchmark data from the Centers for Medicare & Medicaid Services. Your regional Medicare contractor may use its own distribution percentages for benchmarking; you may want to check to see if these are available.

Keep in mind that Medicare data may not be representative of services provided to a younger population. For another resource to assist in this analysis, see “How to Analyze Your E/M Coding Profile,” FPM, April 2007.


Send your comments to fpmedit@aafp.org. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.


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