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Utilization Benchmarking Audit Tool


View sample Utilization Benchmark Profiler report with charts
Use this MDTool to compare a physician's or an entire practice's evaluation of and management (E & M) CPT® code utilization to peers in the same specialty and locality. The distribution of utilization by code within each E & M subcategory is compared to the distribution of paid Medicare claims for physicians in the same specialty nationally and in your Medicare payment locality (2022 Medicare Part B Physician/Supplier Procedure Summary data) . Utilization benchmarking assists physicians and practice managers and administrators in identifying outlier patterns of E & M coding habits. These patterns may indicate poor coding practices which could potentially raise significant billing compliance issues in a practice. Poor coding practices may also produce consistent under coding which would result in lost revenue and also raise a Medicare flag for under serving the population.

Note: If you should find that your data deviates significantly from national and local norms, an appropriate next step may be a focused coding audit. The E & M CPT Coding Review and Audit MDTool can be useful in such an audit.

To begin using this tool, we recommend that you generate a procedure productivity report by provider or practice for a specific date range from your practice management system. There are 48 E & M codes that we can evaluate and benchmark for you.

Benchmarking comparisons are with the Medicare Part B Physician Summary Procedure Summary data file released annually, for the prior year's data, by CMS. MDTools updates this data annually so that benchmark comparisons are with the most recent file available.

Privacy Note: MDTools does not retain any data submitted by users for the purpose of using these tools.



Related Topics

2022 Medicare Fee Schedule

2021 Medicare Fee Schedule

2020 Medicare Fee Schedule

2019 Medicare Fee Schedule

2018 Medicare Fee Schedule

2017 Medicare Fee Schedule

2016 Medicare Fee Schedule

2015 Medicare Fee Schedule

2014 Medicare Fee Schedule

2013 Medicare Fee Schedule

2012 Medicare Fee Schedule

2011 Medicare Fee Schedule

2010 Medicare Fee Schedule

2009 Medicare Fee Schedule

2008 Medicare Fee Schedule

2007 Medicare Fee Schedule

2006 Medicare Fee Schedule

2005 Medicare Fee Schedule

2004 Medicare Fee Schedule

2003 Medicare Fee Schedule

2002 Medicare Fee Schedule


Georgia Medicare Fee Schedule

Florida Medicare Fee Schedule

North Carolina Medicare Fee Schedule

South Carolina Medicare Fee Schedule

Tennessee Medicare Fee Schedule

Mississippi Medicare Fee Schedule


Physician Reimbursement

Physician Fee Schedule

CMS Fee Schedule





Related Web Sites
  • CMS/Medicare Fee Schedule Lookup
  • Download Medicare Fee Schedule
    • Utilization Benchmarking Audit Tool Form
    Please enter the required information below to complete your E&M utilization review benchmarked against 2022 Medicare Physician Supplier Procedure Summary data.


    1.  Enter a practice or physician name:
    2.  Select your specialty:
    3. Enter the zip code where you practice:
    4. Date range from:     To:  
    5. Enter your CPT utilization data below:


    CPT CODE  Description Utilization/Frequency/Units
    New Patient Office Visits
            99201NEW PATIENT - FOCUSED
            99202NEW PATIENT - EXPANDED
            99203NEW PATIENT - DETAILED
            99204NEW PATIENT - COMPREHENSIVE
            99205NEW PATIENT - COMPLEX
    Office Consults
            99241CONSULT - FOCUSED
            99242CONSULT - EXPANDED
            99243CONSULT - DETAILED
            99244CONSULT - COMPREHENSIVE
            99245CONSULT - COMPLEX
    Office Visits-Established Patients
            99211EST PATIENT - MINIMAL
            99212EST PATIENT - FOCUSED
            99213EST PATIENT - EXPANDED
            99214EST PATIENT - DETAILED
            99215EST PATIENT - COMPREHENSIVE
    Initial Observation Care
            99217HOSP OBSERVATION-DISCHARGE SERVICES
            99218HOSP OBSERVATION-LOW COMPLEXITY
            99219HOSP OBSERVATION-MOD COMPLEXITY
            99220HOSP OBSERVATION-HIGH COMPLEXITY
    Hospital Admits
            99221INITIAL HOSP CARE-LOW COMPLEXITY
            99222INITIAL HOSP CARE-MOD COMPLEXITY
            99223INITIAL HOSP CARE-HIGH COMPLEXITY
    Subsequent Observation Care
            99224SUBSEQUENT OBSERVATION CARE
            99225SUBSEQUENT OBSERVATION CARE
            99226SUBSEQUENT OBSERVATION CARE
    Hospital Visits
            99231SUBSEQ HOSPITAL VISIT - FOCUSED
            99232SUBSEQ HOSPITAL VISIT-EXPANDED
            99233SUBSEQ HOSPITAL VISIT-DETAILED
            99234OBSERVATION-DETAILED
            99235OBSERVATION-COMPREHENSIVE
            99236OBSERVATION-COMPLEX
            99238DISCHARGE DAY SERVICES 30 MIN OR LESS
            99239DISCHARGE DAY SERVICES OVER 30 MIN
    Hospital Consults
            99251HOSPITAL CONSULT - FOCUSED
            99252HOSPITAL CONSULT - EXPANDED
            99253HOSPITAL CONSULT - DETAILED
            99254HOSPITAL CONSULT - COMPREHENSIVE
            99255HOSPITAL CONSULT - COMPLEX
    Emergency Room Visits
            99281E.R. CARE - FOCUSED
            99282E.R. CARE - EXPANDED
            99283E.R. CARE - DETAILED
            99284E.R. CARE - COMPREHENSIVE
            99285E.R. CARE - COMPLEX
       
    References
  • National & Locality data from 2022 Medicare Part B Physician/Supplier Procedure Summary

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