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Using Medicare utilization data to identify potential coding issues

Physicians should be aware of practice patterns, documentation guidelines.

Issue: August 1, 2004

ByDonna McCune, CCS-P, COE

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Issue

A solo ophthalmologist practicing general ophthalmology struggled with the transition from use of ophthalmology CPT codes (920xx) to use of the evaluation management (E/M) CPT codes (992xx). Without careful review of the criteria for the E/M codes, the physician began to file claims, generally applying CPT codes 99214 and 99215.

The Medicare carrier selected the physician for a comprehensive medical review due to a significant variance between his practice patterns and those of his peers. The carrier review determined that the documentation did not support the level of care billed for several of the claims in the sample. The carrier issued an overpayment determination relating to the E/M codes used during the period in question.

How could the physician identify the potential problem before Medicare identified it?

Utilization profiles are a useful tool for Medicare carriers as an indicator of potential problems. Physicians can use similar information to predict areas of potential scrutiny by comparing their practice patterns with national norms. Physicians should recognize that using such data is not foolproof, as practice patterns throughout the United States are not uniform, and there may be special circumstances that support extraordinary utilization rates. As always, the chart documentation must support the service. Nevertheless, these data can serve to identify potential problems early.

In the case study, it would have been useful if the physician knew that his utilization of high-level exams was disproportionate to Medicare’s expected utilization. Special circumstances did not exist to support the extraordinary rates. The 2000 BESS data for the codes in question provide a frame of reference:

• Nine of every 100 established patient exams filed by ophthalmologists were filed with 99214.
• One of every 100 established patient exams filed by ophthalmologists were filed with 99215.
• Thirty-three of every 100 established patient exams filed by ophthalmologists were filed with 92014.

Beyond the utilization data, the physician should have paid close attention to the stricter documentation guidelines associated with 99214 and 99215 as compared to the ophthalmology codes (920xx).

In 1997, the Center for Medicare and Medicaid Services (CMS) released documentation guidelines for single-system specialty examinations utilizing E/M codes. E/M code documentation has three components: history, examination and medical decision-making. The 1997 guidelines provide specific criteria for the ocular examination. The history and decision-making components are consistent for all specialties. The higher-level E/M codes (992x4 and 992x5) require extensive documentation for these three components.

While CMS has not published a national policy for the ophthalmology CPT codes (920xx), many Medicare carriers publish “General Ophthalmological Services” local policies. There are, however, differences among the policies. In the absence of published guidelines by a carrier, the CPT handbook provides documentation requirements.