Evidence: Using the same four codes can be a concern

Background

Doctors often find themselves in the rut of using the same CPT codes on every patient, every visit. This looks like a rut because it could appear that no clinical decision making is applied, and everyone gets the same thing. Sometimes, that’s simply how it is. A straight chiropractor using only chiropractic manipulative treatment (CMT) codes would have his treatment look the same all the time. However, the large majority of medical necessity issues that exist in our profession are from the head down, plowing through, do the same four codes on everyone system that statistics reveal upon audits.

This problem is evidenced by recent reports from no less than the Office of Inspector General (OIG) of the Dept. of Health and Human Services. In a recent internal audit of statistical records of 75 doctors, four major coding issues bubbled to the top.

The following data was gathered:

1. Monthly statistics of total office visits, total new patients, total services rendered, and total collections.

2. Reimbursement data gathered for each code billed with allowable amounts recorded from each carrier the office deals with.

3. Numbers of codes billed per month, per CPT code

Issue 1: Number of missed billing/coding events

The number of new patients (NP) recorded in active statistics was compared to the total number Evaluation and Management codes billed, using 9920X codes added to 9924X codes in the same period. The numbers should match. However, 24 percent of the offices had numbers that did not match, where the statistical number of NP exceeded the number of NP codes billed. Two reasons this could occur are if NP are counted in some unusual way, and a coded NP is different from a physical NP. However, more often the problem is the lack of billing NP exam codes. This is not only a compliance problem, but potentially a legal issue, so be sure you bill every NP correctly.

Issue 2: Established patient evaluation and management codes are under billed

The total number of NP evaluation and management codes (9920X plus 9924X) should typically be half the number of established patient EM codes. Logic dictates that if a patient receives a re-evaluation every four weeks as is usually required by third party payers, and even if the patient is discharged before another four weeks, they would have a minimum of two established patient EM codes to every one NP EM code. This doesn’t take into account the number of returning patients whose initial visit warrants an established patient EM code. Unbelievably, the doctors surveyed had the recommended number only 19 percent of the time.

The main reason reported was that they get too busy to do the re-evaluations, which leaves us with documentation concerns. Many major carriers require a DC to show progress within two to four weeks of starting care, and without these re-evaluations, the data can’t be gathered. Or they are doing the evaluations, and NOT billing for it, which is a different kind of compliance concern, due to the Federal inducement rules.

It’s not only a documentation concern. We established the projected number of established patient EM codes that we’d typically see, which was twice the number of NP EM codes. We then calculated the total number of actual established patient EM codes billed in the period, and subtracted that from the total projected number. We were left with the number of EM codes left on the table. Then we multiplied that number by average reimbursement for that EM code to see how much revenue was lost. This number was a staggering average of $8,957 per doctor, per year. An example of the formula is as follows:

Total NP EM codes billed in a year: X=1000

Total expected number of established patient EM codes: 2X=2000

Total number of established patient EM codes reported by Dr. Y = 1200

The difference between the expected number of established patient EM codes and actual: 2000 – 1200 =800

Average reimbursement calculated from all carriers for CPT code 99213, the most common established pt. EM code used = 34.50

Estimated amount of lost revenue = 800 X 34.50 = $27,600

We are not suggesting that every patient requires 99213, but for illustration purposes, these codes should be reviewed in each office on a regular basis. It’s clearly both a documentation and a revenue related issue.

Simple reviews of coding data can reveal a myriad of problems and help to create solutions. Every practice is encouraged to follow the recommendations of the OIG to complete internal audits on a regular basis.

This research was provided by KMC University.

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