Busted Bell Curves # 1
The frequency at which physicians report follow-up evaluation and management codes (99211 – 99215) can be graphed in a way that facilitates visual benchmarking. When individual physicians report services in a pattern that deviates substantially from the average for his/her specialty, Medicare frequently sends a correspondence with comparative bell curves that illustrate the deviation. Some physicians adjust billing to be more in-line with the average. This can easily cost over $50,000 per year.
Keep in mind, the appropriate level of service is dictated by the content of the visit note not a probability distribution. As such, utilizing bell curves to assess the accuracy of assigned CPT codes is not statistically sound. To assess accuracy, one must conduct audits.
The bell curves that Medicare uses are flawed. General cardiologists should report higher than “average” levels of service, interventional cardiologists should report more high-level services than general cardiologists, and electrophysiologists should report more high level services than any of the others. Until recently, all three of these groups were included in, and compared to, the same bell curve. It was not an apples-to-apples comparison.
Medicare now recognizes electrophysiology and interventional cardiology as separate specialties. On October 1st, they will begin recognizing “Advanced Heart Failure and Transplant Cardiology" as another. All three were previously included in the cardiology bell curve.
The bell curves being created by the three new specialties will haunt them for years. Without accurately reporting higher levels of service when it is appropriate, physicians will create an artificially deflated bell curve that they will be compared to for a long, long time.
In this “Busted Bell Curves” series of posts, I will explain why the bell curves are flawed. I’ll also explain what percentage of services should be reported at the highest levels for general cardiology, interventional cardiology, and electrophysiology. Finally, I’ll present easy adjustments doctors can make to insulate themselves from under documentation penalties.
Why is the bell curve flawed?
One reason is that it includes data from all claims submitted by all physicians who are registered as cardiologists in the Medicare system. This includes claims submitted under a cardiologist's name for services rendered by supervised nurse practitioners, physician assistants, and registered nurses. The bell curve also includes services billed by physicians who only practice cardiology part time. Full-time cardiologists should be reporting more of the high level services than the bell curve reflects..Strip out all services rendered by someone who is not a full-time cardiologist and the cardiology bell curve will shift to the right.
Another reason for a deflated bell curve is physician intimidation. Most cardiologists will admit that they are not well-versed in the documentation and coding guidelines that apply to evaluation and management services. I believe that doctors who comply with the documentation and coding guidelines will report many more 99215s than would appear normal in the bell curve.
My next post will explain what percentage of services should be reported at the highest level by general cardiologists, interventional cardiologists, and electrophysiologists. I’ll present the logic behind my position so physicians can make fully-informed decisions.
As is the case with all services you bill to Medicare, there must be medical necessity for the history, exam, and complexity documented in your note. These documentation components must support the level of service you report. There are many nuances associated with applying Medicare's documentation standard to the cardiology specialty. I've gotten several physicians out of over billing situations by explaining basic anatomy and common abbreviations like PSVT.
Are you ready to be audited?
The Cost of an Audit