Avoid Audits by Using National Averages as Guide
Published on Thu Jun 01, 2000
By Eric Sandham, CPC
Neurosurgery Coding Alert Consulting Editor
Compliance Educator
Central California Faculty Medical Group
Fresno, Calif.
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 analysis 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 neurosurgeons. The statistical analysis contractor is a consultant for the Medicare Integrity Program, usually a medical director 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 neurosurgery services. The Healthcare Financing Administrations (HCFA) national data for neurosurgeons are 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 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 neurosurgery, 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 [...]
