Neurology & Pain Management Coding Alert

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 this pattern will bring, since you may be flagged for an audit.


The top level of service decreased in every category of E/M service in 1999, both in absolute numbers and as a proportion of the codes. Most of this shift was to level four for new patient office/outpatient visits (99204), and to level three initial inpatient consultations (99253) and established patient office/outpatient visits (99213). Code 99213 would typically describe a clinic or office visit for patients requiring an adjustment of their seizure medication.

On the other hand, if you are using a higher proportion of level-one and level-two visits, you may be losing revenue because of undercoding. This holds true for initial inpatient consultations (99251-99255), where level-four and level-five codes make up 83 percent of the category. Level-three codes are only 13.5 percent of the total.

If overcoding is found, knowing your variance can assist in adjusting coding practices to avoid extra paperwork from focused government audits. While there will be significant divergence in coding and documentation standards, HCFA expects these standards to converge with increased auditing. Where a practice is in relation to national standards is important to HCFA, and neurologists should become aligned to avoid the chance of auditing.

The May edition of Neurology Coding Alert contained an article showing how and why to compare utilization date to the Health Care Financing Administration (HCFA) national averages. Please call our customer service department if you would like to receive a copy.