Neurology & Pain Management Coding Alert

An innocuous-looking letter arrives in your office, one of the many official-looking pieces of mail you receive on any given day. On behalf of the Medicare Integrity Program, an organization established through the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to perform statistical analyses of Medicare claims, the letter requests supporting documentation of dozens of high-level office consultations. Youve just come under the watchful eye of a statistical analysis contractor because your use of high-level codes significantly exceeds national averages for neurologists. The statistical analysis contractor is a consultant for the Medicare Integrity Program, usually a medical director, RN or CCS whose agenda is to analyze claims data and preselect claims that have a high probability of fraud and abuse.

Benchmark Data to Avoid Audits

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 proper coding and billing receive optimal ethical reimbursement for neurology services. The Healthcare Financing Administrations (HCFA) national data for neurologists is outlined in the table on this page.

The first step in preparing your data for comparison with the HCFA data is to choose a time frame. It is not necessary to use 1998 data, and in fact it is probably better to use data that reflect your recent practice patterns. It can be useful to look at Medicare population only, and compare that data to total patient population to see if there is any variance.

Most medical billing software can provide reports of your usage by procedure code. If you are part of a group practice, try examining how your usage patterns compare to those of other physicians in the group, as well as to the HCFA data.

Because you cannot match HCFAs absolute numbers, you need to find out the proportions of code usage. This can be determined by figuring the percentage of a category a procedure code usage represents. The formula for this is to divide the total number of encounters for a specific code by the sum of all encounters in that category, and dividing it by 100.

Data Comparison Analysis

Now that the data are lined up next to HCFAs data, two things should be examined and compared: the usage profiles of all E/M services, and 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 patient visits are billed as new patient office visits (99201-99205), you might be mistaking consultations for referrals. Similarly, the majority of subsequent inpatient visits are billed with codes 99231-99233. If most subsequent inpatient visits are billed as follow-up consultations (99261-99263), you may be overusing the consultation codes. It will be only a matter of time before this type of anomaly comes to the attention of the statistical analysis contractors, resulting in an audit.

Next, look at the usage profile within any given category. 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 using these codes at more than twice the national average. That does not mean you are using them inappropriately, but it does mean you should be sure that your documentation supports the scrutiny this pattern inevitably will bring. Likewise, if you are using a higher proportion of level-one and-two visits, you may be losing legitimate revenue because of undercoding. This holds true for initial inpatient consultations (99251-99255), except that it is level-four and-five codes that make up 85 percent of the category. Level-three codes are only 11 percent of the total.

With an audit, HCFA may want to use your information to uncover possible overcoding. Even though not all practices will be in perfect alignment with national averages, knowing your variance can assist you in adjusting your coding practices to avoid extra paperwork from focused government audits and possible fines and recoupments if overcoding is found.

Consequently, adjusting your coding practices to be more in alignment with national norms can result in proper and possibly additional reimbursement. Yet there still will be significant divergence in coding and documentation standards. As HCFA expands its auditing and enforcement, these standards are expected to converge. Where you stand in relation to national standards is important to HCFA because neurologists should become more aligned to avoid the necessity of auditing. Use these tools for your protection and practice improvement.