Benchmarking Evaluation & Management Codes

With the advent of EMRs, doctors are now able to track, monitor and visualize data that was not as easy to obtain as before.

One data set that EMR systems feature, are E/M codes. E/M codes, if you are not familiar with the term, stand for Evaluation and Management. E/Ms are represented by CPT codes 99211-99215.

Evaluating your practice’s CPT data is highly beneficial because the data reveals insights into the practice. For example, gathering E/M codes allows you to analyze each code’s distribution (e.g., how many 99213 is the practice ‘or a provider’ coding in comparison to 99214).

But how does one know if the distribution is a proper distribution? In other words, if a practice’s 99213 is two times greater than 99214s, is that good or bad?

My go-to guy for this sort of questions is Chip Hart. Chip has access to large data sets over the span of many years thanks to his company’s customers. And when it comes to this sort practice management analysis stuff, Chip is the biggest nerd I know.

Coincidentally, Chip posted on SOAPM a response that addressed this very question of E/M code distribution and what is an appropriate benchmark for pediatric practices.

I took Chip’s response (with his permission) and adapted it for the blog post. Enjoy:


B: You’ve done some work on E/M distribution, have you not?

C: I’ve done a lot of work on the semi-mythical E/M distribution topic.

B: OK, let’s get to it. What is the E/M distribution benchmark practices should use?

C: I want to mention a few things first.

  1. We are talking about Pediatrics data specifically. What Family Practice does, for example, is interesting or helpful in an argument, but really doesn’t pertain to pediatrics.
  2. I’m assuming that you really want to know what practices are DOING, not in fact what they SHOULD be doing. There is a difference.

B: Anything else we should know before you share the data?

C: Yes, let me remind you that what other people are doing should only act as a mild guidepost…just because a practice’s distribution is different doesn’t mean the practice is safer or losing money or whatever.

B: This sounds like an important point to highlight.

C: I know practices who do a great job with 60% 99214s and I know practices who should be in jail for their 15%.

B: Give me the bottom line then.

C: The bottom line is this, providers should chart what they did [in an exam] and code what they chart. Nothing more, nothing less.

B: Noted. Now, let’s get to the data.

C: Here’s some real pediatric data from millions of pediatric visits.

Screen Shot 2015-11-08 at 4.36.35 PM
2010 – 24% | 2011 – 25% | 2012 – 27% | 2013 – 29% | 2014 – 30% | 2015 – 31%


B: I’m confused by the numbers… I thought you were going to share with us a bell curve. What did you do here?

C: To provide a single, simple number, I just add the 99214s+99215s and divide it by the total 99212-99215 set.

B: What about the 99211?

C: In this benchmark, I am only looking at 99212s through 99215s.

B: Why is that? The 99211 are part of the EM codes.

C: Pediatricians shouldn’t be doing 99211s, and the “normal” curve does imply that pediatricians do as many 99214s as 99213s, for example.

B: Your “simple” single number changes the bell curve.

C: The peak [of the bell curve] is between the 99213 and 99214, not the 99213.

B: Let me see if I understand. To calculate my practice’s E/M distribution, I add all the 99214s and 99215; then I add all the 99212 thru 99215; and finally, I divide the total of 99214 and 99215 by the total of 99212-99215. Correct?

C: Yes.

B: Walk us through the interpretation of the result.

C: Looking at the chart above, for 2015, our clients bill a 99214 or 99215 31% of the time they do an E/M.

B: This way of calculating and benchmarking E/M distribution is different. E/M distribution charts traditionally show the percent for each code for a specific time.

C: I think this data is a lot better than the MGMA data for a variety of reasons (namely sample distribution).

B: What about wellness codes that were billed with an E/M code, do you factor them in?

C: This [data] does not include 9921X codes done during a well visit (i.e., 99213-25).

B: Are we talking new and established E/M coded or just established?

C: The data I shared above does not include NEW 9920X codes;

It is important to reiterate that while Chip’s data represents millions of pediatric claims, you should use Chip’s data as a reference among many.

In other words, just like a sailor uses multiple navigation tools and visual aids to determine its position, speed, and course – instead of a single reference point – you should use additional data points to determine how well your practice is doing.

Don’t forget to visit Chip’s blog Confessions of a Pediatric Practice Management Consultant

Seven Reasons Why You Don’t Want To Miss This Pediatrics Practice Management Seminar

My friends at the Pediatric Practice Management Institute (PMI) have an awesome seminar that you don’t want to miss.

Why should you not miss it?

Glad you asked.

I have lucky number 7 reasons why you should not miss this seminar.


I know awesomer is not a word. But it gets’s the point across. Here is the deal, no matter how experienced you are at managing a practice, there is always something new you can learn.


Managing a private practice can be a lonely world. There aren’t that many of us. And most of the time we are locked up in a back room (used for both your office and storage) trying to figure out how to keep the ship afloat.

Without exposure to a variety of points of view, you will miss new ideas and trends that can impact future results.


Paul and his team at PMI have put together a superb curriculum. The educational materials will certainly expose you to new ways of managing your business (e.g., private medical practice) and help you discover how to be more productive.


Here is the way I see it. The practices that tend to go to practice management seminars are precisely the practices I want to learn from. And PMI’s seminar provides a great opportunity to network with the best practice in the country.


Not only will you have access to a community of like-minded people that have similar struggles, have similar challenges and practical, hands-on advice, suggestions, and solutions, you will also have access to the industries top consultants.

Don’t tell them I said this, but if you ask the right questions, to say… Chip Hart, I bet you, you’ll get thousands of dollars worth of practice management advice for <ahem> free.

Keep in mind that experts in the field are some of the best people for you to get to know if you want to learn more about the current health care business climate as it relates to small, private, independent, pediatric practices.


You will undoubtedly discover innovative ways to help your practice remain competitive in today’s fast-paced, hectic private-practice.


Did I mention it was in Vegas?

All work and no play can get old fast. PMI’s conference can add a layer of enjoyment to managing your career growth by mixing a social aspect into your learning and industry branding efforts.

Never underestimate the power of a little fun mixed with some interesting people!


Use the promo code “PediInc” and save $75 off your conference fee.

Conference Details:

  • WhenFriday, January 29, 2016 at 2:00 PM –  Saturday, January 30, 2016 at 5:00 PM (PST)
  • WhereTropicana- Las Vegas
  • Sign Up: Click on the Eventbrite logo below to sign up

Don’t forget to use the promo code PediInc to get $75 off

10 CPT Codes You’re Most Likely Under-utilizing

I found myself sitting next to four pediatricians during the hospital’s pediatric departmental meeting. The four docs were engaged in conversation by the time I sat down at the round table.

They were talking about coding. Specifically about 99213 and 99214. “Do any of you bill level 4s?” asked the one sitting across me. ” I can’t remember the last time I coded a level 4. I just don’t have that many emergencies,” replied the doc next to me.

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The pediatrician that sat across from me followed up in a justifying manner stating, “I keep it simple… level 3 all across the board. I don’t want to raise any red flags with the insurance companies.”

Judging by their nods, all four pediatricians seemed to agree.

Except for me, of course. But I couldn’t say anything because I was recovering from the feeling you get when somebody scratches their nails across a chalkboard.

You’d be hard press to find a cardiologist or orthopedist say; I keep my coding simple so that I can stay under the radar. But pediatricians are, well, pediatricians. And because of who they are and what they do, they are notorious for under-coding (most of them).

But that doesn’t mean we should give up on pediatricians. If anything, we should be motivated to work extra hard to get the word out on proper coding.

Below I’ve highlighted commonly underutilized codes in pediatrics; including level 4 and yes, level 5 (did you even know there was a level five?) in the hopes you or your staff will become aware of these codes and remember to use them.


According to the AAP, 99214 and 99215 (established patient office or other outpatient services) represent only 20% and 5%, respectively, of all evaluation and management codes submitted in pediatric claims.

What does this mean? That most pediatricians don’t code/bill for level 4 or 5s despite having done the appropriate work.

Don’t be afraid of coding level 4 and 5s. If you follow the requirements set forth by CPT and document the chart accordingly, you’ll realize levels 4 and 5 reflect your work with the patient more than a level 3.


If so, you can bill for consult codes 99241, 99242, 99243, 99244, and 99245 ( office or other outpatient consultations)

You may overlook consult codes because pediatricians are not specialist. However, a surgeon, for example -with all their specialized training – won’t even give a kid Tylenol without clearance from their primary doctor. Thus, pediatricians are indeed consultants.

There are a few requirements to bill this code. For example, follow-up with the requesting physician (i.e., the surgeon) with a written report or a hospital’s standard pre-op form.


As the doctor places her hand on the doorknob after completing an exhausting well-visit, she ask the parent, “…is there anything else?”

The phrase, is there anything else? is doctor code for, we’re all done here, I got to go. For the parent, it’s an invitation, of course. What else would it be?

“There is,” says the mom. ”

If you decide to address the issue right then and not ask the parent to come back, you are performing two significant, separately identifiable evaluation, and management services during the course of a single visit.

Therefore, you should attach modifier 25 to the office or other outpatient service code and list that in addition to the preventive medicine service code.

An example of this is preventive medicine service with an acute swimmers’ ear.The preventive medicine service may be linked to Z00.129 while the office or other outpatient service may be linked to H60.339 (swimmer’s ear, unspecified ear).


Do you see patients on a scheduled holiday? Do you see patients late into the evening? How about on Sundays? Do you see patients on Sundays? If you answered yes to any of these questions, you could code 99051 for every visit in addition to the E&M code.

CPT defines this code as service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic services.


Nursemaid’s elbow is a common occurrence in the pediatric population. Do you know that you can code for the treatment of it?

Code 24640 (closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation) may be reported as well as an evaluation and management code if a significant, separately identifiable evaluation and management service is provided.

If this is the case, attach the modifier 57 (decision for surgery) or the modifier 25 (significant, separately identifiable E/M service) to the associated evaluation and management code.


Case management is a process whereby a physician is responsible for direct care of a patient and for coordinating and controlling access to or initiating and/or supervising other health care services needed by the patient.

Sounds complicated. But it isn’t.

Do you spend time on the phone with parents? How about emails or portal messaging?

If you spend a lot of time communicating with parents, either on the phone, email, portal or phone app, you can bill for case management codes.

Although the chances the practice will receive payment for these codes is slim, coding experts and practice management consultants insists it is still a good idea to bill for what you do.

Therefore, whether you communicate with the patient via phone (99441-99443 or e-mail 99444), you are providing care for the patient and should bill for your services.


Let’s say a mom brings her daughter in because she suspects she is a victim of child abuse.

According to the APP, the pediatrician is required to perform a complete evaluation and management service in addition to an anogenital exam with colposcopic magnification.

With an example like this one, you should report both the evaluation and management service and the colposcopy. For the anogenital exam, use code 99170.

Don’t forget to add modifier 25 to the evaluation and management code to “alert” the insurance processing the claim the fact that you performed a significant, separately identifiable evaluation, and management service in addition to the colposcopy during a single visit


Have you received a call from a parent at the end of the day asking if her child can be seen? And because you can’t bare the thought of the child suffering for another 12 hours or feel guilty telling the parent to go to the ER, you and a few staff members end up staying after regular office hours to see the child?

If it has happened to you, make sure that you are billing for 99050 in addition to the E&M code

This code is for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed.


Imagine for a moment that instead of a mom calling your office at the end of the day, she shows up mid-morning with a wheezing kid.

Do you see that patient right away, essentially on a “walk-in” basis and make all other patients wait?

If you do, you should be billing for “service(s) provided on an emergency basis in the office, which disrupts other scheduled office services” (99058) in addition to the evaluation and management code.


Do you screen or ask parents to complete forms that aid in the assessments of a child’s development? For example, manage developmental screening tools such as Developmental Screening Test II, Early Language Milestone Screen, PEDS, Ages and Stages, and Vanderbilt ADHD rating scales?

If so, you should be reporting it using CPT code 96110 (developmental testing; limited) or 96127 (brief emotional/behavioral assessment)

Keep in mind that the purpose of this post is to bring to your attention a handful of codes that pediatricians don’t use as often as they should. I’d suggest finding coding and billing resources that go in depth into each of the codes supplied in this post, as well as provide a plethora of other underutilized code.

Pediatric Practice Management Seminar You Don’t Want To Miss

The content in many practice management seminars or conferences are either too generic (the one size fits all medical specialty approach) or too specific (subspecialty focused) in my view. As a result, it makes it difficult sometimes to figure out how to apply the lessons from other medical specialties to pediatrics.

If only there was pediatric specific seminar, where everybody in attendance speaks yScreen Shot 2014-11-21 at 10.10.07 AMour language (the language called Pediatrics), are aware of my specific challenges and when I receive advice, tips, suggestions or recommendations, it is provided with in the context of pediatrics. Wouldn’t that be great?

Well, our prayers have been answered.

My friends at the Pediatric Management Institute have put together an awesome line-up of speakers (Disclosure: I’m one of the speakers. But I’m not including myself among the awesome ones), presentations and case studies for a one day seminar in the San Francisco/Oakland area that you will not want to miss.

This one day seminar packs a lot of information. Here’s a glimpse of the topics that will be discussed:

  • Coding, The Basics and Beyond
  • Set Your Practice Prices Fairly and Easily
  • Brave New World: Future Pediatric Models
  • Key Performance Indicators for Pediatric Practices
  • Easy Methods to Collect Patient Balances
  • The 5 Legal Issues To Watch Out For In a Pediatric Practice
  • Top 10 Coding Lost Opportunities
  • Five Concepts to Maximize Your Marketing
  • When to Add Another Provider to Your Practice
  • ICD-10, Ready or Not!
  • Patient Recalls
  • Budgeting for a Pediatric Practice

Whether you are an expert in practice management, employed by a large health organization or just starting to learn about how to properly manage a medical office, this seminar offers a valuable learning opportunity.

But wait… there is more!

The PMI team is holding the seminar at the Holiday Inn & Suites Oakland Hotel Airport , which as the name implies, is right next to the Oakland airport. No need to rent a car or arrange for additional transportation. You’ll be right there. Fly in. Attend the seminar. Fly out.

For a PDF on the topics, speakers, location and date (Saturday January 24, 2015)  click on the link: Pediatric Management Institute Seminar

Psst…. one more thing.

If you use the code “PediatricInc” when you register, you will receive $75 off your registration. How cool is that? This offer is exclusive to PediatricInc readers. Now you can bring someone along and save $150.00. If you bring one more person, you’ll save $225.00… it’s like the gift that keeps on giving. 🙂



Increase Your Medical Practice’s Bottom Line In One Easy Step

A few months before we opened the practice, we picked up a flyer inviting doctors, billing and coding staffers to attend a coding seminar in town.  It looked like something we ought to go considering we were about to open our very own private practice and had zero billing and coding knowledge.

Screen Shot 2014-11-26 at 2.57.08 PM

About one minute into the lecture, I was lost. I had no idea what they were talking about. I was merely a marketing guy and had no idea about managing a practice, let alone billing and coding.

But I didn’t worry. My wife was a few years out of residency at the time, so this logical questions ran through my mind: surely this coding thing was still fresh in her mind?

As the trainer continued talking in a foreign language (I later found out was divided into two dialects, CPT and ICD9) I assured myself …doctors are taught this peculiar character/numerical dialect during medical school and then get the change to master it during residency. It would be as foolish as having a sail boat with no sails to not teach doctors how to bill and code. Besides, how do you pass the boards without knowing billing and coding? 

I had nothing to worry about.

What? You’re as clueless as I am? Didn’t you pass the boards? You mean to tell me that in those 3-years they didn’t even give you a lunch seminar on how to get paid for your work?

My next thought was, Oh boy! We are a deep, deep, sh… I mean 787.91.

Here is the thing, as ridiculous as not teaching residents at least the basics of billing and coding may sound, what’s more ridiculous, is that many doctors don’t do anything about it. Few docs – knowing very well that billing is coding determines their pay – learn how to document and code properly. Many don’t even go to coding seminars regularly.

Instead, may docs (not the ones that read this blog, of course) blame health insurance companies or blame their EMRs for getting payed less while to do more. All of which is likely true.

But here is a hard truth. If you’re a health provider and you do not take the time to learn and stay current with with coding and billing guidelines, then you need to get the list of all the things you blame for declining pay and write your name at the top of that list.

Why? Because the loss of revenue is happens in your examining room as a result of poor documentation and poor coding. 

Fundamentally, most pediatricians are doing the work. But because they lack knowledge and awareness on how to document and bill as a result of not keeping up to date they are leaving countless dollars – dollars they’ve worked for – on the table.

It also is worth mentioning that relying on your billing and coding team is not an excuse to not to keep up to date on coding and billing guidelines. To put it in perspective, putting all the responsibility on your billing and coding department is like asking your nurse or MA to take full responsibility for your patients.

And I’m not diminishing the role of clinical support staff or the coding and billing department. My point is that RNs and MAs, as well as billing and coding personnel, are there to assist.

If want to improve your medical practice’s bottom line in one easy step, all you need to do – for starters – is:

Attend a coding seminar,  pronto!

I’ll guarantee you’ll increase your bottom line.

You’re welcome!

#20 Key Performance Indicators Smart Practice Managers Measure [Pediatric Practice Management AwesomeCast]

Screen Shot 2013-11-07 at 7.42.08 PMFor today’s AwesomeCast, I invited my friend Paul Vanchiere from the Pediatric Management Institute. Apparently, Chip had more important things to do… Pfff. Family. So he was MIA for this recording.

If you don’t know about the Pediatric Management Institute, make a note to visit. Paul and his team are doing some really cool things to help pediatric practices manage their business better.

Paul knows a few things about key performance indicators, why they are important, and most important, how to calculate them. So I sat down with him and asked him a few questions regarding the topic.

On the AwesomeCast, Paul shares with us an area on his website where you can find explanations, formulas, examples and descriptions for all the key performance indicators.

For details check out this link: Calculators – KPI 

And if you want to learn about the seminars Paul and his crew is doing around the country, visit: PMI Seminars

Here are other ways you can check out the AwesomeCast:

Are You Happy With Your Compensation?


My buddy and co-host on the Pediatric Practice Management MediaCast has put together a Pediatric Compensation Model Survey on SurveyMonkey.

The purpose of the survey is to find patterns of compensation model satisfaction among private pediatric practices.

Here is Chip in his own words:

In more plain language, I want to get to the core of why some practices are so much happier than others when it comes to how they pay themselves.

I invite anyone in the private pediatric world – practice owners, employed physicians, nurse practitioners, practice managers – to participate.

Chip is going to be sharing a summary of the findings and results with anyone who participates and provides contact information.

But that is not all, if you call now… sorry. Couldn’t resist.

But there really is more. Those that participate will be entered to win an iPad mini (winner selected at random). Pretty cool, right?

To give you an idea of the type of pediatric practice management data gold that Chip is mining, here’s a little glimpse from the preliminary data Chip has already collected.

For those for whom productivity is a measured part of the compensation model, the most popular methods of measure are:


The survey should only take a couple of minutes.  And please share this with all your friends! The more data Chip has, the better the results will be.

How Many Billers Should A Medical Practice Employ?

med-billing-and-codingWe’ve talked about in-house billing vs outside billing before. I even teamed up with my friend Chip Hart and devoted a full podcast to the topic. But we’ve never talked about billing staff ratios. How many billing staff should we have? How do we know if we are understaffed or overstaff?

Should we calculate the ratio based on charges and collections or should we base it on physician count?

Dr. Suzanne Berman, one of the many outstanding contributors to the SOAPM list serve and an avid supporter of the Survivor Pediatrics Blogs, jumped in to the discussion with excellent insight on how she staffs her office. Here is what she had to say.

One full-time biller could probably do 65% of our 5-provider practice. This would essentially involve simple in-and-out: convert all the superbills to claims, send ’em out, then post whatever she gets back, and send a bunch of statements, then deposit whatever we get.

A colleague of mine (who probably thinks I’m overstaffed) does just this very thing with a single part-time biller.

This physician is happy to collect 65% of his claims with hardly any effort and write off the rest — which also gives him hardly any days in AR (“oops, they didn’t pay for imms with an EPSDT? OK, I guess we’re writing that off. Next claim!”)

65% is the easy low-hanging fruit. Another FTE might do another 20% — but it’s the next hardest 20% (appeals, corrected claims, etc.) which require more skill. Another FTE will do the very hardest 10%. This gets us to 95% of collections, or so.

Then I have to decide if another FTE could get me 2-3% more collections, and is it worth it, and (perhaps most importantly) does that newly-added FTE have the skill set to squeeze out that very-difficult-to-get 2-3%? If I add another FTE, it needs to be a Claims Commando, not a “worker bee” whose main skill is being fast and accurate entering data on a 10-key

I’d like to jump in here and add that I think there needs to be a person in charge of working the patient balances. This is the person that is calling patients informing them of their balance, explaining to them why they have a balance, writing and sending collection letters and setting patients up on payment plans.

Dr. Berman brought up another very important point that one must consider when deciding how many “billers” an office should have. She writes:

The other related question is: who’s a biller? I know this sounds dumb, but a lot of the important billing functions revolve heavily on the front desk doing their job (at least, that’s how the work is divided up in my office):

  • validating insurance for each and every visit
  • collecting copays
  • getting correct addresses, phone numbers, email addresses, etc.
  • updating VFC status
  • figuring out which of the divorced parents is supposed to be paying

If you have receptionists who are not doing these jobs consistently, more work is going to devolve to the billing office to track down this information when the patient isn’t in the office. On the other hand, if you have an extra receptionist up front who does all the insurance validation the day before and runs a list of people coming in who need to be squeezed for $$, you can get by with fewer billing people. Or should I say, “billing” people. I think billing + reception = a constant (when it comes to total collections effectiveness, that is.)

Dr. Berman doesn’t answer the question, but with her approach, she is teaching us how to fish, as opposed to simply giving us the fish. I like this approach better.

But for those of you that don’t have the patiences, time or interest, I have something for you too. My friend Chip Hart also chimed in and he summarized it like this:

I usually expect at least 2:1.

Professionally I know Chip enough to know that with this statement, he isn’t saying this is a set in stone, hard-rule type statement. So don’t misinterpret his simple statement. He acknowledges that every office is different, different factors affect different things in an office. But if you want a hard rule of thumb, then the 2:1 (2 docs for every 1 biller), is a good start.

How many billers do you have in your office? What do you think is the right number? How many is too many? Does more billers equal better collections for your office? Drop a line. I’d love to learn from you too.

Episode 3: What To Look For When Selecting A Medical Billing Company

We recorded another video… I think we are actually getting better at this.

For this video, Chip and I talk about Billing Companies. Chip shared seven tips that ought to be on everybody’s mind if they are considering going with a medical billing company.

I shared with Chip our experience billing services, in-house billing and what circumstances have led us to have the setup we currently have; which I describe as a hybrid model.

We also discussed our thoughts on when it is appropriate to use a billing company, what to look for in a contract and how the practice should set up their front desk to maximize collection efforts.

Take look at the video for more practice management gold nuggets.


By the way, feedback is always welcome. We are all ears.