Audits uncover coding and billing errors related to physician/practitioner services
Background
ClaimDOC’ s comprehensive line-by-line auditing of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings to health plans and beneficiaries. Our audit team analyzes all types of healthcare claims for a variety of potential concerns including excessive usual and customary charges, duplication of claims, correct coding initiative (CCI) edits, unbundling of services, and others. Our claims review is not intended to impact care decisions or medical practice.
In this claims audit spotlight, we focus on physician/practitioner (professional) services related to coding and billing.
Professional services billing is the reporting/billing of claims for services performed by physicians or other qualified healthcare professionals. Generally, claims are submitted electronically on the 837-P form or paper version, CMS-1500 claim form. Physician/professional services may include:
- Diagnostic, such as radiology, laboratory, or other diagnostic or therapeutic testing.
- Treatment, such as certain procedures/surgery and chemotherapy.
- Wellness and prevention, such as counseling and other evaluation and management services.
- Rehabilitation, such as physical, occupational, or speech therapy, cardiac rehab, pulmonary rehab, drug or alcohol rehabilitation, and others.
Pricing and payments for professional services are commonly based on a physician fee schedule. Medicare’s physician fee schedule provides information for more than 10,000 physician services, the associated relative value units (RVUs), a fee schedule status indicator, and various payment policy indicators needed for applicable payment adjustment. Pricing amounts are adjusted to reflect the variation in practice from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure’s RVU (i.e., RVUs for work, practice expense, and malpractice).
Case Scenario One
Member was seen in an office setting by a nurse practitioner located in the state of Georgia for the diagnosis of muscle strain in the abdomen due to overexertion.
The nurse practitioner reported/billed an office visit using CPT code 99203. This code is defined as:
“Office visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of the total time is spent on the date of the encounter.”
As part of our claims analysis, ClaimDOC uses up-to-date benchmark data/tools to determine the range of practitioner charges by practice locality.
For this practitioner’s service location, the mean/average charge billed by physicians/practitioners is CPT code 99203 – $220.00.
Below is an overview of the nurse practitioner’s charge she reported/billed on the claim and ClaimDOC’s related pricing and savings:
- Total nurse practitioner charge for CPT code 99203, new patient office visit: $4,400.20
- Medicare pricing based on 2021 physician fee schedule: $106.82
- ClaimDOC Pricing: $133.53
- Plan Savings: $4,266.67
- Percentage of Savings: 97%
Case Scenario Two
Another member was seen by the same nurse practitioner referenced above at the same office location for the diagnosis of unspecified skin rash. The nurse practitioner reported/billed an office visit code 99204, injection CPT code 96372, and medication code J2930.
CPT code 99204 is defined as:
“Office visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision making. When using time for code selection, 45-59 minutes of the total time is spent on the date of the encounter.”
CPT code 96372 is defined as, “Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular.”
HCPCS code J2920 is defined as, “Injection, methylprednisolone sodium succinate, up to 40 mg.”
For this practitioner’s service location, the mean/average charge billed by physicians/practitioners is:
- CPT code 99204 – $310.00
- CPT code 96372 – $47.00
- HCPCS code J2920 – $21.00
Below is an overview of the nurse practitioner’s charge she billed and ClaimDOC’s related pricing and savings:
The nurse practitioner’s charges included:
- CPT code 99204 for $5,000.90
- CPT code 96372 -injection of medication for $320.00
- HCPCS code J2930 Methylprednisolone medication for $270.00
- Total billed charges: $5,590.90
- Medicare pricing based on the physician fee schedule, CPT code 99204: $160.47
- Medicare pricing based on the physician fee schedule, CPT code 96372: $13.29
- Medicare pricing based on ASP Drug Pricing Files: HCPCS code J2930: $5.45
- ClaimDOC Pricing: $224.01
- Plan Savings: $5,366.89
- Percentage of Savings: 96%
The Takeaway
Egregious charges for physician/professional services were noted on these claims. While physicians/practitioners may elect and bill any amount they choose for services(s) performed, egregious fees complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of charging high fees and create burdens for patients having no insurance and a host of others.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.