Orthopedic Coding Alert

Auditors stress that they want to see a bell curve when comparing statistics from an individual practice to national averages. Therefore, if your orthopedic practices stats show a predominate pattern of high-level codes, they figure youre probably upcoding. A way to protect yourself is to review statistics like carriers would.

An increasing number of commercial insurance companies and Medicare carriers alike are using practice utilization statistics from the Health Care Financing Administration (HCFA) to evaluate practices (including orthopedics) for fraud, abuse, and waste. Therefore, coding predominately just one level of evaluation and management (E/M) services (i.e., 99205, 99215, 99223, 99233, 99245, 99255) or one category, such as consults (99241-99255), is downright risky, warn the nations top coding experts.

The [insurance carriers] computers use these statistics to find out how often your practice bills services and procedures in comparison to other practices of the same specialty across the country, explains Susan Callaway-Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott, Davis and Co., LLP, a healthcare accounting and reimbursement firm in Augusta, GA.

The HCFA statistics include the number, by specialty, of every CPT code billed out at least 10 times in one year.

Patterns that are most likely to cause a further review include straight lines instead of bell curves, and bell curves that are weighted heavily to one side or another, explains Callaway-Stradley, who is also the American Academy of Professional Coders (AAPC) 1998 Coder of the Year.

For example, if the bell curve for your practice showed an inordinate percentage of level five services, auditors might see it as a signal that an overpayment had occurred, says Georgette Gustin, CPC, CCS-P, president-elect for the AAPC, and director of the Health Care Regulatory Group for Pricewaterhouse Coopers LLP, in Detroit, MI.

Most carriers will consider a 15 percent or more variance from the national standards as a reason for closer inspection, adds Callaway-Stradley.

Naturally, the curves that are heavily weighted to the high side will be scrutinized since the potential for overpayment is obvious, but many carriers are also looking at those practices that err to the low side of the curve, she says. The thought process is, Maybe we wont find any overpayments with their E/M services, but they may have other problems from which we can recoup payment because they dont seem to understand the basics of coding.

It Pays to Watch the Numbers

These numbers are being employed to monitor your practice, so you should also know them. Benchmarking your E/M services is a great first step to avoiding problems now and in the future, Callaway-Stradley explains.

For example, if your practice has or is planning to institute a compliance plan, comparing utilization [...]