CPT Coding Audits for Compliance and Better Reimbursement
INSURANCE CODING
Kathy Mills Chang
MCS-P, CCPC, CCCA
Tracking your individual code usage is very important when you need to prove compliance, and it can really affect your bottom line. It’s easy to fall into the trap of using the same code repeatedly, even though it may not be the most appropriate code to use. There are several guidelines you can follow to see how your ratios compare to other national averages. It’s important to understand that these are guidelines; we are not recommending ways to fool insurance companies or increase your reimbursements.
So what are we suggesting? Well, start with your computer system; it should provide you with a list of codes and their usage. Next, gather some data from your practice management software and conduct a search for the report that outlines the codes you entered for the period you want to audit. For example, if you decide on July 1 to audit the past six months of usage for your practice, you’ll want to search for monthly reports from January through June. The report you get back should show the total occurrences for each month and the code you entered into the system. For subsequent audits, you may be able to gather the comparison data for the full period, rather than month by month. If you’re not sure how to gather this data, check with your practice management software support team because they’re a great resource. Once you have your report, use the recommendations below to see if you are within the normal code-usage limits.
Your report format should resemble something like this:
Analyzing Your Coding Data
“That sounds intimidating! I’m not an analyst,” you say. So what are you going to do with all of that data now that you have it? If you stick to the following simple guidelines, then evaluating and managing your E/M codes won’t be that difficult.
1. For each new patient E/M code (9920X), there is typically an X-ray code (if you routinely X-ray patients as part of a normal protocol, this applies). Add the total number of new patient E/M codes (9920X) and compare the results with your X-ray log. If your normal protocol is to X-ray patients at the beginning of care, you can also compare this data to the series of X-ray of codes. The reasoning behind this is that most new patients have at least one X-ray series. However, some will have more than one, and a few won’t have any at all.
2. For each new patient E/M code (9920X) there should be at least twice the number of established patient E/M codes (992IX). The rationale is that each patient you see should have at least two reevaluations, even if treatment was short-term and you’re conducting a discharge examination. You should strive for a ratio of at least 2:1, with established patient exam codes at least double the new patient exam codes. This process does not take into consideration reactivating patients (those returning with new conditions) or any other situations you have for established patient E/M codes, so using the 2:1 ratio is a conservative estimate.
3. If you’re looking at multiple levels of E/M coding for both newand established-patient visits, you might expect that a variety of codes were used. If a single
code was used primarily for new-patient evaluations and a second code used primarily for establishedpatient evaluations, the payer might assume the doctor was unsure of how to code for these types of visits. If you bill the same level of E/M visit codes for a large percent of your patients, you’re creating an overcoding/undercoding scenario.
Active/Passive Procedures:
So what does all that mean?
1. Well, to start, the totals for codes 97530, 97112, and 97110 should be approximately twice the total of your passive modality codes if your practice has an active care component because passive modalities should drop off after the first month of treatment.
2. The total number of 97110 codes should equal at least 50% of your total CMT codes since, in today’s functional model of care, it’s important to deliver active care in your practice. Doing so shows that you are delivering care aimed at functional restoration.
3. Next, compare the total number of97140 codes billed with the number of 98941 CMT codes used. While there are no standard, recommended percentages or ratios for this data, if a 98941 was billed to a patient on a particular day, then it would be unusual to see a
97140 billed to that patient on the same day. This is a gray area because a 97140 performed on the same region that was included in a CMT code would not be billed separately.
4. A high number of 97140 codes could indicate that you are billing excessive units, especially if they exponentially exceed the total number of CMT codes for a practice during this period. Because this therapy code describes a very intensive type of treatment, it is medically unlikely that any patient could tolerate multiple (three or four) units on each visit.
CMT Codes:
So how do CMT codes factor into all of this information?
1. CMT usage across the three spinal codes may vary depending on your practice style, your adjusting techniques, and other factors. Typically, we’d expect to see from 40 to 60% of your codes divided between 98940 and 98941, with a very low percentage showing for 98942 (e.g., you might see 55% for 98940, 40% for 98941, and 5% for 98943; or 35% for 98940, 63% for 98941, and 2% for 98942. These estimates are based on CMS data for relative chiropractor usage).
2. The total number of 98943 codes should be ap-
proximately 25 to 40% of the number of spinal CMT codes, depending on how likely it is that you will be treating extra spinal regions. The rationale behind this thinking is that an approximate number of patients in a given population require additional care for extra spinal regions.
You’ll be well served if you perform these coding audits on a regular basis, use these guidelines to be sure you’re considering all of the data, and record your findings in your compliance manual. Document any areas of concern, create strategies to correct any problems you uncover, and detail any training you’ll implement to address any needed corrections. Establishing a solid process to follow allows you to stay on top of any potential problems associated with the overuse of certain codes when coding ratios are out of sync with expected norms.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P), a certified chiropractic professional coder (CCPC), and certified clinical chiropractic assistant (CCCA) Since 1983, she has provided chiropractors with reimbursement and compliance training, advice, and tools to increase revenue and reduce risk. Kathy leads a team of 20 at KMC University and is considered one of our profession ,’s foremost experts on Medicare, documentation, and compliance. She or any of her team members can be reached at 855-832-6562 or info(a),kmcuniversity.com.
