Overcoding issues

[Guest guest]

I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help.

I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records.

My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the "bell curve" is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more "sick" patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the "new" visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a "normal" bell curve, but I could be just rationalizing all of this to support my data!

My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to "prove" to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to "tick off" this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas.

Any ideas would be appreciated.

Sue