This comprehensive report offers analysis of Evaluation and Management 4/5 level by member, provider, specialty, and type of service over specified time periods. The point of service, the diagnosis, and procedures accompanied by the risk scores describe member activity at a level of detail that drives population health management strategies specific to provider services.
Target Audience for this Report
Chief Medical Officer, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, Quality Management, and Utilization Management.
Business Impacts of this Report
Comparative data which describes provider services supports provider education and improvements in care delivery. The CMO and Medical Management department can track and trend E&M codes to create provider profiles which leads to development of high performing networks. E&M codes represent an indicator for patient risk and identify a need for care management and follow up.
E&M code data when compared with ED visits for the same population creates a detailed perspective of the population and utilization patterns. This leads to a greater understanding of member choice and the access of care by providers. Cost savings identified must be actualized through provider monitoring and education. E&M coding is monitored by CMS as well as health plans and comparative data is available to share with providers and across the health plan. While health plans cannot instruct providers how to code, comparative data can be powerful to alert providers to trends and outliers.
Details and Definitions
It should be noted that the header KPIs in this report “Total E&M Claims”, “Total Level 4/5 Paid”, “Level 4/5 Paid/Claim”, “Potential Savings” and “%Procedure Level 4/5” do not change when filters are applied within the visualization. The header information will change with the application of platform or page filters.
E&M CPT codes included in this report are: 99201, 99211, 99241, 99251, and 99281 (all level 1); 99202, 99212, 99242, 99252, and 99282 (all level 2); 99203, 99213, 99243, 99253, and 99283 (all level 3); 99204, 99214, 99244, 99254, and 99284 (all level 4); and 99205, 99215, 99245, 99255, and 99285 (all level 5).
Note that filtering order in the visualization is:
- Specialty Type (% Level 4/5 per Specialty Type) bar chart (select one or more bars).
- Provider type (% Level 4/5 Specialty Type) table (select one or more rows).
- Top Groups by Level 4/5 billing table (select one or more rows).
% Level 4/5 per Specialty Type (Graph)
- Specialty Type
- Percentage of level 4 and 5 submitted
% Level 4/5 Specialty Type
- Specialty
- Patients
- Level 4/5
Groups by level 4/5 Billing
- Billing Group
- Patients
- Level 4/5%
- Paid
- Savings Opportunities
% Procedures by Level 1-5 (by Selected Provider) (Graph)
- Percentage by Selected Provider
- E&M Level
% Procedures by Level 1-5 (by Selected Specialty) (Graph)
- Percentage by Selected Provider
- E&M Level
Member Details
- Member Number
- Member Name
- Risk Score
Member Details
- Member Number
- Service Date
- POS
- Diagnosis
- Procedure
- EM Level
The bar chart “% Level 4/5 Specialty Type” shows the percentage of level 4/5 billing by provider type.
The table “% Level 4/5 Specialty Type” shows the provider types, with the number of patients, and the percentage of overall cases that are Level 4/5.
The table “Top Groups by Level 4/5 Billing” shows all of the provider groups, the number of associated patients, the percentage of level 4/5 cases, the change rate for that statistic, a visual indicator of that change rate, and the associated savings opportunity (if any). See the Glossary for that calculation.
The bar chart “% Procedures by Level 1-5” shows the percentage for the selected provider(s) for overall E&M levels.
The table “Visits Detail by Member and Visit Date” shows the members and detail (including place of service, diagnosis, procedure, risk score, and E&M level) for the selected provider group(s). “Member Name” field is a hyperlink to the member’s profile.