Cardiology Coding Alert

How do you know if your practice will be flagged for an audit? Dont speculate anxiously; use hard numbers to determine whether your coding variances are higher or lower than normal, says Susan Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, headquartered in Greenville, SC.

Comparing your practices utilization data with national norms will yield invaluable information.

1. Avoid an audit. If your practice is within 10% of the national standard, you probably are not going to be flagged for an audit, she explains. If its 10% to 15% above youre pushing the envelope, but theres still some chance that they wont get around to you.

At 15% to 20% above national norms, youre looking at an audit. Its not a matter of if; its a matter of when, Stradley warns.

2. Determine reimbursement. Similarly, such benchmarking can show you where you are undercoding. If the practice is under the national standard or very high in low-level visits, then you may be losing money, she says.

For example, cardiologists who code too high on new patient visits, but too low on established patient visits, might make an extra $15 the first time they see a patient, but then lose money every time thereafter, she explains. And what do you see more of, established or new patients?

Stradley adds, that national statistics indicate that 35% of new patient visits are overbilled, and 70% of established patient visits are underbilled.

Here are the most common codes that may be undercoded and losing your practice money:

99212 to 99213: established patient, office or other outpatient visit

99201 to 99202: new patient, office or other outpatient visit

99241 to 99242: new or established patient, office or other outpatient consultations

3. Contract negotiations. Information about utilization patterns can be vital when negotiating contracts with payers, adds John Burns, consultant with The Medical Management Institute in Atlanta, GA. Ive seen physicians get excited [when initially skimming a contract] that generously reimbursed for level five visits and consults. Yet, the majority of their patients would not warrant this level of coding. So before you sign you must know the bread-and-butter codes of your practice; otherwise, you might short-change yourself, he cautions.

Dont Stop with the Results

Benchmarking alone doesnt solve anything; it just points out the problems, Stradley cautions.

It also isnt perfect. Remember these are statistics and averages; your utilization pattern may be higher depending on your patient mix and location, she adds.

For example, if your practice is the only one in a small town, you may have a higher percentage of patients in acute care, she says. Or, if you are in a large city with multiple cardiology practices, you may choose not to do certain [...]