CPT fee differentials and visit upcoding under Medicare Part B

Medicare Part B pays outpatient physicians according to the billed Current Procedural Terminology (CPT) codes, which differ in procedure and intensity. Since many performed services merely differ by intensity, physicians have an incentive to upcode services to increase profitability of a visit. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper explores the effect of Medicare Part B fee differentials on the upcoding of general office visits (i.e. for established patient visits with CPT codes of 99212‐99215). It finds strong evidence that these fee differentials influence physician's coding choice for billing purposes across a variety of specialties. For general office visits, Medicare outlays attributable to upcoding may sum to as much as 15% of total expenditures for such visits. Medicare has much to gain financially by clarifying its classification rules. Until the distinctions between types of Medicare visits are redefined in a way that eliminates ambiguity, upcoding under Medicare Part B is likely to continue. Copyright © 2010 John Wiley & Sons, Ltd.     

Coding and reimbursement of primary care debridement and excision procedures.

Current medical practice requires physicians to accurately report services provided to patients. Patient billing for debridement and excision procedures involves the selection of specific 1992 Physicians' Current Procedural Terminology codes. Although a site-specific surgical procedure code often yields higher reimbursement than a general procedure code, physicians should select the code that most accurately reflects the procedure performed. This review identifies the codes used to report destruction and excision procedures performed by primary care physicians. Included in this review are skin debridement, burn debridement, excision of benign and malignant lesions of the skin and subcutaneous tissue, cyst and ganglion excision, nail excision, anorectal lesion excision, shave, paring, and skin tag excision procedures, and foreign body removal. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions are provided for selecting between multiple coding options when more than one code describes the service provided.     

Variability in code selection using the 1995 and 1998 HCFA documentation guidelines for office services. Health Care Financing Administration

BACKGROUND: Documentation guidelines have been developed by the Health Care Financing Administration (HCFA) to promote consistent selection of physician evaluation and management (E & M) codes. Our goals were to determine whether medical providers and auditors agree in their assignment of office codes using 1995 and 1998 guidelines and to ascertain if the code levels assigned are affected by auditor experience and training. METHODS: A total of 1,069 established patient charts from private family physician offices were reviewed by a family practice faculty physician, a family practice resident physician, and a professional coder. The main outcome measures were the agreement between the auditors and the medical care provider on code selection and the degree to which documentation supported the code selected. RESULTS: All auditors agreed with the medical provider code selection in only 15.2% (1995 guidelines) and 29.2% (1998 guidelines) of visits. Professional coders were more likely than faculty physicians or resident physicians to agree with the code assigned by the medical provider (51.7% vs 40.7% and 39.6%, P <.001). Documentation adequately supported the most common office code selection, 99213, in 92.7% (1995) and 91.0% (1998) of the charts reviewed. Concurrence among all auditors was only 31.0% (1995) and 44.3% (1998). CONCLUSIONS: Interobserver differences exist in the assignment of E & M codes by auditors using both 1995 and 1998 HCFA guidelines. The 1998 documentation guidelines produce greater agreement among auditors. The documentation supported the level of code billed in the majority of established patient office visits.     

Billing practices of North Carolina family physicians

BACKGROUND. This study describes billing practices of family physicians. Significant increases in the reimbursement for family physicians are expected from implementation of the resource-based relative value scale (RBRVS). However, the real impact of the RBRVS is unknown since little is known about how family physicians use the present reimbursement system to charge their patients. METHODS. A random sample of 270 North Carolina family physicians was surveyed, using standardized progress notes of five hypothetical patients. RESULTS. One hundred thirty-eight (51%) physicians responded; 107 (77.5%) were in private practice. Family physicians in private and nonprivate practices were similar in their Current Procedural Terminology (CPT) coding and level of service for each hypothetical case. Family physicians in smaller communities showed greater variation in CPT coding of visits than did family physicians in larger communities, and they were more likely to use CPT codes that indicated a lower level of visit. Rural family physicians demonstrated a significant inverse relationship between the CPT level of visit coded (ranging from "brief," with a CPT code of 90040, to "comprehensive," coded CPT 90080) and the amount they charged established patients for a "limited" visit (CPT 90050). CONCLUSIONS. These findings suggest that the lower income of rural physicians is due, in part, to billing at a lower CPT code, and thus charging less for comparable services, than urban physicians. The findings also lend further support to contentions that federal reimbursement reforms will have less impact on the incomes of rural physicians than originally expected.     

Accuracy of CPT evaluation and management coding by family physicians

BACKGROUND: Limited data are available on physicians' accuracy in coding for their services. The purpose of this study was to determine the current procedural terminology (CPT) evaluation and management coding accuracy of family physicians and define demographic variables associated with coding accuracy. METHODS: Six hundred randomly selected active members of the Illinois Academy of Family Physicians were sent six hypothetical progress notes of office visits along with a demographic survey. The study group assigned CPT evaluation and management codes to each of the progress notes and completed the demographic survey. Five expert coders also assigned codes to each of the cases. The accuracy of family physicians in determining CPT E/M codes was determined relative to that of expert coders. RESULTS: Family physicians agreed with the experts' CPT evaluation and management codes for 52% of established patient progress notes, the most common error being undercoding. In contrast, for new patient progress notes, family physicians agreed with the experts only 17% of the time, the predominant error being overcoding. No surveyed demographic variable was associated with coding accuracy. CONCLUSIONS: The error rate for physician CPT coding is substantial and occurs more commonly with new patients. The complexity of the CPT coding guidelines, along with limited physician training in CPT coding, likely account for these results.     

Coding and reimbursement of primary care biopsy and destruction procedures.

Current medical practice requires physicians to accurately report services provided to patients. Billing for destruction of benign and malignant lesions and for surgical, needle, and endoscopic biopsy procedures involves the selection of specific 1992 Current Procedural Terminology (CPT) codes. Payment for these procedures by third-party payers often requires the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding for neoplastic lesions. This review explains the proper codes to use in identifying common biopsy and destruction procedures performed by primary care physicians. The Health Care Financing Administration's relative value units and one state's published Medicaid payment rates are included for each procedure code. Instructions for selecting site-specific biopsy and destruction codes are provided.     

Current Coding Practices and Patterns of Code Use of Registered Dietitian Nutritionists: The Academy of Nutrition and Dietetics 2013 Coding Survey

Coding, coverage, and reimbursement for nutrition services are vital to the dietetics profession, particularly to registered dietitian nutritionists (RDNs) who provide clinical care. The objective of this study was to assess RDN understanding and use of the medical nutrition therapy (MNT) procedure codes in the delivery of nutrition services. Its design was an Internet survey of all RDNs listed in the Academy of Nutrition and Dietetics (Academy)/Commission on Dietetics Registration database as of September 2013 who resided in the United States and were not retired. Prior coding and coverage surveys provided a basis for survey development. Parameters assessed included knowledge and use of existing MNT and/or alternative procedure codes, barriers to code use, payer reimbursement patterns, complexity of the patient population served, time spent in the delivery of initial and subsequent care, and practice demographics and management. Results show that a majority of respondents were employed by another and provided outpatient MNT services on a part-time basis. MNT codes were used for the provision of individual services, with minimal use of the MNT codes for group services and subsequent care. The typical patient carries two or more diagnoses. The majority of RDNs uses internal billing departments and support staff in their practices. The payer mix is predominantly Medicare and private/commercial insurance. Managers and manager/providers were more likely than providers to carry malpractice insurance. Results point to the need for further education regarding the full spectrum of Current Procedural Terminology codes available for RDN use and the business side of ambulatory MNT practice, including the need to carry malpractice insurance. This survey is part of continuing Academy efforts to understand the complex web of relationships among clinical practice, coverage, MNT code use, and reimbursement so as to further support nutrition services codes revision and/or expansion.     

Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic

PURPOSE: To compare a template-driven medical documentation system to undirected handwritten documentation and determine whether the template (1) decreases physician evaluation time, (2) increases gross billing, and (3) increases physician satisfaction with the documentation process. METHODS: A prospective randomized trial of documentation with a template system (T-System for Primary Care, Dallas, TX) versus undirected handwritten documentation was conducted in 2 separate teams of a single family medicine residency program. After training, one team used the template system and the other team used undirected written documentation. Clinic visit duration was recorded. Medical records were evaluated by a blinded professional coder to assign an evaluation/management code. Clinic visit duration and coding level differences were evaluated using an independent t test. At the conclusion of the study, residents completed a questionnaire to determine physician satisfaction with the documentation tool. Survey responses were on a -2 to + 2 Likert scale. Means and standard deviations are reported. RESULTS: A total of 1339 patients were included in the analysis of patient visits. There was no significant difference in clinic time between the template system and the written documentation visits. The mean visit time was 1.75 hours for both teams. For the analysis of gross billing, 1237 charts were included. The mean billing amount for written documentation was USD $150 and for the template system it was USD $163--a statistically significant difference. The physicians' surveys favored continuing to use the template documentation method. CONCLUSIONS: The template medical documentation system compared with undirected written documentation produced a significantly higher bill for the visit, yielding no differences in evaluation time, and was overall positively received by the residents and faculty.     

Development and evaluation of a charge capture program for long-term care providers

OBJECTIVE: Clinicians often have difficulty determining the appropriate Current Procedural Terminology Evaluation and Management code to assign to the type and intensity of patient care they provide. The purpose of this study was to develop, implement, and evaluate a handheld charge capture program for use by providers in the long-term care setting. DESIGN: Using a pre-post study design, we compared the coding accuracy and user satisfaction of an established paper process with a handheld charge capture program created for this study by means of: (1) preimplementation and postimplementation assessment of coding accuracy, and (2) preimplementation and postimplementation clinician survey. SETTING: We studied an academic division of geriatric medicine. PARTICIPANTS: Participants consisted of six clinicians who currently spend at least 50% of their clinical time practicing in the long-term care setting. INTERVENTION: A handheld charge capture program to replace the current paper-based charge capture process was reviewed. RESULTS: Overall coding accuracy improved by approximately 20% when the handheld program was used instead of a paper coding process. The majority of clinicians found that the handheld program was more widely available, efficient, easier to use, and encouraged the participants to document more completely and accurately in the patient's medical record. CONCLUSION: A handheld billing and coding program used by clinicians who provide care for long-term care residents is not only feasible, but leads to an improvement in coding accuracy when compared with a paper process. In addition, clinician satisfaction toward the billing and coding processes improved with the use of the handheld program.     

Addressing multiple problems in the family practice office visit

OBJECTIVES: The purpose of the study was to describe the number of problems addressed during family practice outpatient visits, the nature of additional problems raised, how they affect the duration of the visit, and how well they are reflected in the billing record. STUDY DESIGN: Cross-sectional. POPULATION: We studied a total 266 randomly selected adult patient encounters representing 37 physicians. OUTCOMES MEASURED: A problem was defined as an issue requiring physician action in the form of a decision, diagnosis, treatment, or monitoring. Visit duration and the number of billing diagnoses were also assessed. RESULTS: On average, 2.7 problems and 8 physician actions were observed during an encounter. More than one problem was addressed during 73% of the encounters; 36% of these additional problems were raised by the physician and 58% by the patient. On average, each additional problem increased the length of the visit by 2.5 minutes (P<.001). The concordance between the number of problems observed and the number of problems on the billing sheet indicated a trend toward underbilling the number of problems addressed. CONCLUSIONS: Multiple problems are commonly addressed during family practice outpatient visits and are raised by both the physicians and the patients. Our findings suggest that current views of physician productivity and the billing record are poor indicators of the reality of providing primary care.     

Accuracy of patient encounter and billing information in ambulatory care.

BACKGROUND. This study examined the degree of accuracy of billing data in an academically affiliated family practice. METHODS. The progress notes from 1253 consecutive visits were independently reviewed by two family physicians, and the diagnoses, use of procedures, and level of service were determined for each visit. Discrepancies between the reviewers were resolved by consensus. These data were compared with the data on the corresponding billing form that had been completed by the care providers (ie, physicians on the faculty, physicians in training, family nurse practitioners, and nurses). RESULTS. There was poor agreement between the billing form and progress note on level of service and number of diagnoses (kappa = 0.37 and kappa = 0.28, respectively). The progress note usually indicated that a higher level of service should have been billed for a visit than actually was billed. Underreporting of the number of diagnoses was substantial; the billing forms listed only 69% of the diagnoses identified in the progress notes. In 60% of visits, each diagnosis on the billing form had a matching diagnosis in the progress note. This could be improved to 78% of visits if broad categories of disease were used. Residents were similar to faculty in the accuracy of reported level of service and types of diagnoses, but were more likely to underreport the number of diagnoses. CONCLUSIONS. Ambulatory care data from computerized billing files may not be sufficiently accurate for proper reimbursement of physician services or for use in research.     

Can primary care physicians use the ICD-9-MC? An evaluation of the quality of diagnosis coding in computerized medical records

OBJECTIVES: To determine the completeness and accuracy of ICD-9-CM codes allocated by primary health care physicians in their computerized medical records and evaluate the effects of improvement procedures. METHODS: The codes of 87,806 patients assigned to 56 primary care physicians in the Basque National Health Service in Spain, were evaluated 3 times over a 1-year period according to the following criteria: correspondence to a valid ICD-9-CM code, agreement between diagnosis and code, and the percentage of visits with an unspecified reason for consultation. Finally, the mean number of unique diagnoses and rates of diagnostic groups in the 84,136 patients that remained with the same physician for a minimum of 6 months were contrasted with another previously registered morbidity database. Two interventions were performed to improve coding: detected errors were corrected centrally and physicians were assessed and given information on their individual results. RESULTS: Diagnoses lacking an ICD-9-DIC code decreased from 59% in the first assessment to 2% at the end of the study period. The percentage of coding mistakes (discrepancies in episode diagnosis and ICD-9-CM code) decreased from 17% to 3%. The mean annual number of diagnoses per patient was slightly lower than that in the reference database (2.26 versus 2.43). The same result was observed in the rates of some diagnostic groups. CONCLUSIONS: Primary care doctors can achieve a high degree of quality in ICD-9-CM diagnosis coding. Implementing procedures for evaluating coding, rectifying mistakes, and providing information to physicians markedly improved the initial results.     

International classification of diseases and current procedural terminology codes underestimated thrombolytic use for ischemic stroke

BACKGROUND AND OBJECTIVE: To determine the accuracy of recently introduced International Classification of Diseases Ninth Revision (ICD-9) procedure and Current Procedural Terminology (CPT) codes designed for injection or infusion of thrombolytic agents. MATERIALS AND METHODS: We determined the accuracy of ICD-9 procedure code 99.10 and CPT codes 37201, 37202 for use of thrombolysis in ischemic stroke by comparing procedure codes of University Hospital discharge data with a concurrent prospective registry. RESULTS: Of the 369 ischemic stroke patients, 49 (13.3%) received either intravenous and/or intraarterial thrombolysis. The sensitivity and specificity for ICD-9 procedure code 99.10 was 55% and 98% and CPT procedure code 37201 and 37202 was 49% and 99%. Identification by either ICD-9 codes or CPT codes yielded a high sensitivity and specificity of 82% and 98%. CONCLUSIONS: The use of ICD-9 and CPT codes alone may underestimate the use of thrombolytics using national and regional database. Best results are achieved when a combination of ICD-9 and CPT codes are used to identify the use of thrombolytics.     

Direct observation of exercise counseling in community family practice

BACKGROUND: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood. METHODS: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis. RESULTS: In 4,215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor. CONCLUSIONS: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.     

Improving the E coding of hospitalizations for injury: do hospital records contain adequate documentation?

OBJECTIVES: Incomplete external cause of injury (E) coding limits the usefulness of hospital discharge data sets for injury surveillance and research. Hospital medical records were examined to determine whether they contained adequate cause of injury documentation to allow for more complete E coding of injury discharges. METHODS: Medical records for a sample of discharges involving a principal diagnosis of injury from the Uniform Hospital Discharge Data Set for Rhode Island were selected. We assigned E codes to these discharges and compared our E codes with those of the discharge data set. RESULTS: Documentation of cause of injury in the medical records was sufficient to allow assignment of a specific E code to 70% of the injuries for which no E codes or vague E codes were submitted on the Uniform Hospital Discharge Data Set. It was estimated that specific cause of injury documentation is available in the medical records of 80% of all injury discharges in Rhode Island; for approximately 90%, an E code describing at least the broad cause of injury could be assigned. CONCLUSIONS: Rates of E coding can be substantially increased by making better use of existing documentation in medical records.     

Towards computer-assisted coding: A case study of ‘charge by documentation’ software at an endoscopy clinic

ObjectivesAn imminent transition to the ICD-10 diagnostic code set has increased interest in automating portions of the reimbursement process for clinical procedures. In this paper, we compare two distinct sets of billing codes generated at an endoscopy clinic using a traditional manual methods and computer-assisted coding using a ‘charge by documentation’ approach.MethodsThis is a retrospective, cross sectional research design analyzing data collected from all patients treated at one outpatient endoscopy clinic from July 2010 through June 2011. The collected data were the medical record number, data of service, diagnosis, procedure, CPT codes, ICD-9-CM codes, and CPT modifiers. The paired data were categorized as either an exact match or discrepant.Results98% of the 2923 procedures were either colonoscopies or upper GI endoscopies, which have predictable workflow deviations that reliably map to changes in procedural and diagnostic codes. The codes from the two methods were an exact match for 31% of the cases. The automated approach generated 1–8 additional codes for 62% of the cases, and the manual approach generated codes without accompanying supporting documentation in the progress note for 24% of the cases.ConclusionsWe conclude that the automated approach was superior to the manual approach. We recommend the ‘charge by documentation’ approach for settings where the workflow is relatively predictable, including pre-identified frequently occurring branches to the workflow that affect the selection of procedural and diagnostic codes.     

Sensitivity of Claims-Based Algorithms to Ascertain Smoking Status More Than Doubled with Meaningful Use

Background

The “meaningful use of certified electronic health record” policy requires eligible professionals to record smoking status for more than 50% of all individuals aged 13 years or older in 2011 to 2012.

Pilot educational outreach project on partner violence

BACKGROUND: To assess the impact of a multimodal educational outreach on physician screening and documentation of intimate partner violence (IPV) in primary care. METHODS: Pre- and post-intervention assessment of physician screening and chart documentation of IPV. Physician screening was assessed by post-visit survey of patients and documentation was assessed by medical record review. SETTING: Three medical offices in an urban community of approximately 1 million. PARTICIPANTS: Three primary care physicians (one internist, one obstetrician, and one family physician) and 100 patients from each of these practices. INTERVENTIONS: Multimodal educational outreach to physicians and their office staff regarding appropriate screening and management of IPV. A trained IPV educator made periodic office visits in 2002 to educate the physician and office staff regarding appropriate screening and management of IPV. RESULTS: Before the intervention, 36/150 (24%) of sample patients reported having been previously asked about IPV and 24/150 (16%) reported being asked in a written format. After the intervention, 100/149 (67%) and 41/108(28%) reported being asked verbally or in writing, respectively. CONCLUSIONS: This pilot study of three physicians suggests educational outreach represents a promising and feasible means of improving physician screening and documentation of IPV in primary care.