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.

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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!

#8 Key Metrics We Should Use to Gauge the Financial Health of Our Medical Practice, Part II [Practice Management VideoCast]

Chip and I continue our discussion on key reports we ought to be looking at when assessing the financial health of our practices.

In this AwesomeCast, Chip and I talk about E/M distribution, specifically the 9921x and how looking at these CPT codes and comparing with each other can provide a lot of insight into the clinic’s billing practices, among other things.

We also talk about Sick to Wellness ratio. Chip walks us through his process on determining the sick to wellness ratio and what are the sort of things this report tells him about a practice.

As always, we’ve made the AwesomeCast available in various formats. Check out the links below and find the one that best suits you.

1. Google+ Community

2. Pediatric Practice Management Mediacast PodCast

3. iTunes

And of course, YouTube:

Top 40 CPT’s

I wanted to share our practice’s top 40 CPT codes. I compared them to last years top 40 codes just to see what would come up. The ranking is based on frequency, not of revenue or paid or anything else.

Here it is:

* Service not performed in 2007 / ** Service did not place in top 40 in 2007
* Service not performed in 2007 / ** Service did not place in top 40 in 2007

A few observations:

  1. 99214 made a jump from 5th to 3rd
  2.  96110 dropped a spot. But it’s OK since it gave the spot up for 99214, which pays better anyway.
  3. 99392 made a jump from 10th to 6th
  4. Lots of U/A’s relative to other codes
  5. 92587 (hearing screen) came in 12th place. We bought the device in the fall of 2007. I’m happy to see that we are using it a lot. It is a great device to have for school physicals. Not only does providing the hearing screen a great complement to our comprehensive pediatric exams, it also reimburses really well.  
  6. 99212 drop considerably. I think my docs are wising up on their coding and figured out they were leaving money on the table.
  7. Look at our 99051. Chip would be proud.

What are your thoughts on our top 40 CPT codes? Do you see problems with it? Are they similarities with your top 40? Do you see something that could be improved? Do you see something that you currently aren’t doing that may implement?

Love to hear your thoughts.


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Increase Revenue By Attending Coding Seminars

Either way, I encourage you to promote to your doctors the importance of attending coding seminars. They add a lot of value and ultimately, revenue to the practice.


The other day I went to a pediatric coding seminar sponsored by one of the hospitals in the area. As I was sitting down, two physicians were chatting next to me. One of the docs said to the other, “…we come to these things all the time. This is probably our 10th year.” The other physician – apparently attending his first coding seminar – said, “Wow! Every year? Doesn’t it become monotonous hearing the same thing year after year?” The other physician explained that the seminar contained new materials and that every year they learn news things. “In fact,” said the doctor, “my office manager and head nurse come with me every year” suggesting the seminar was that important.

I came to the realization that there is such a need to educate doctors about medical coding.  If anything, the naive doctor should have at least known that ICD-9 and CPT codes are revised and changed every year. That reason alone is enough to justify going to a coding class at least once a year.

Every year, I attend at least one coding seminar. And every year I come back with lots of information and tips. But it seems increasingly more difficult to schedule time and sit down with my doctors to relay what I had learned. Sometimes, I got a few minutes, but usually, we never got around to it.

Last year, I decided to do it different. We closed the office for a day and I sent both of my doctors to a coding seminar. We had concerns about closing the office, like loss of productivity or if a patient got really sick. Despite those concerns, (the doctors remained on-call for emergencies of course) I thought a single day at a coding seminar would be worth it.

And it was. The doctors enjoyed the seminar immensely. They learned a great deal. They returned motivated and with a new outlook on how they diagnosed and coded for their services; which increased revenue in just a few weeks.

A few months later, I ran several reports and found new CPT codes the doctors started using as a result of attending the seminar. To our surprise, the codes not only had been reimbursed, but the codes had generated enough revenue to cover the expense of sending the docs to the seminar.

If closing is not an option, you can set up a lunch – or an after hours sessions – and make arrangements for a coding specialist to visit the office. Another idea is alternating doctors if you have coverage issues.

Either way managers ought to find ways for doctors to attend coding seminars. They add a lot of value and ultimately, revenue to the practice. I understand that most physicians are overwhelmed as it is with our current medical system. But coding is their livelihood. If doctors do not understand the intricacies of medical coding, they are in essence leaving money on the table. As a practice manager, we should try to do more to keep our doctors informed about changes in CPT codes, billing issues and new coding tips.