Avoid Audits by Comparing Code Use to National Averages
Published on Fri Dec 01, 2000
By Eric Sandham, CPC
Compliance Educator
Central California Faculty Medical Group
Fresno, Calif.
National neurology code usage statistics can help you catch problems and avoid audits. Under the Medicare Integrity Program, statistical analysis contractors will be comparing physicians code utilization patterns to national averages. This will include neurology practices. Those with unusual or potentially abusive coding patterns may be audited.
HCFA Administrator Nancy Ann Min-DeParle recently released a memorandum indicating that Medicare will be looking closely at 99214 and 99233. In the memorandum, she noted that These codes accounted for a significant portion of the coding errors in the last two audits. In fact, documentation for many of these services was found to be sufficient to support services more appropriately described by 99212 and 99231.
Neurologists with a high proportion of these charges will have their documentation reviewed. Comparing your data to national averages is not just a means of foreseeing and avoiding a potential audit. This type of comparison, also called benchmarking, can be an important tool to ensure that your neurology services are being properly reimbursed.
HCFAs national data for neurologists are outlined in the table below.
Steps for Data Comparison Analysis
1. Compare your Medicare population to total patient population to see if there is any variance. Most medical billing software can provide reports of your usage by payer and procedure code used.
2. If you are part of a group practice, examine how your individual usage patterns compare to those of other physicians in the group, as well as to the HCFA data.
3. Line up your data next to HCFAs and look at:
a) the usage profiles of all evaluation and management (E/M) services individually;
b) the usage profiles for each category of E/M services (office visit, consultations, etc.). For neurology, the majority of new patient visits are inpatient and office consultations (99251-99255, 99241-99245). If the majority of new visits are billed with 99201-99205 (new office visit) you might be confusing consultations for referrals. Similarly, the majority of subsequent inpatient visits are billed with 99231-99233. If most of your subsequent inpatient visits are billed as follow-up consultations (99261-99263), consultation codes may be overused.
c) the usage profile within any given category. (As in the 1998 chart, which appears in the May 2000 edition of Neurology Coding Alert, about 80 percent of established patient office visits (99211-99215) are level three and four, and only about 10 percent are level five. If more than 20 percent of encounters for this category are level five, you are billing these codes at more than twice the national average.
Note: This does not mean you are using them inappropriately, but you should be sure that documentation supports the scrutiny [...]
