FP Report -- April 1999
Downcoding?
Patients with three or more chronic medical problems typically have visits that could be coded as 99214.Your insurance carrier worries about upcoding, but you probably claim too little pay.
You may downcode every day and lose pay.
Codes for visits of established patients range from 99211 (minimal service) to 99215 (highly complex), and you may purposely aim low.
"Internists and pediatricians tend to charge for a much greater percentage of 99214 and 99215 visits," said Nancy Wilson Ashbach, M.D., of Denver. "FPs charge for a much higher percentage of 99212 and 99213 visits."
A member of the AAFP Commission on Health Care Services, Ashbach until recently worked for an insurance company and saw evidence of FPs' downcoding in a study of 700 Denver-area doctors.
She sees more evidence auditing family physicians' coding patterns as their consultant. They worry that if they code at the right level and don't document the visit perfectly, they'll be accused of fraud.
"They opt to see patients faster, code at a lower level and not take the chance that their coding might be challenged," said Ashbach.
Ashbach's advice: Use a preprinted form to document the components of each complicated visit. For examples of forms, see "Three Documentation Tools That Work" from the January 1998 Family Practice Management.
Hire QI/UR manager
Another commission member suggested hiring a quality improvement/ utilization review manager.
"You're busy seeing patients all day," said Charles "Shot" Rodgers, M.D., of Little Rock, Ark. "You may not have time to make sure systems are set up to prevent fraudulent claims. A good embezzler can take your code, upcode it and take a slice of what you were overpaid."
In Rodgers' practice of 30 physicians and three clinics, the QI/UR manager established systems to prevent fraud, unnecessary services and referrals to facilities in which the physician has a financial interest. In addition, the physicians and staff attend coding seminars regularly.
"Eight years ago, my average code was 99212, and now it's 99213 with some 99214s," said Rodgers. "I probably don't bill for as many 99215s as I should. But I'm coding better, and my documentation is better."
Track compliance
The Office of Inspector General estimates that improper payments under Medicare's fee-for-service system in fiscal year 1998 totaled $12.6 billion -- far less than the $20.3 billion estimate for 1997.
The OIG attributes the decline to the government's battle against Medicare fraud and to physicians' improved compliance with reimbursement rules.
To insulate your practice from a federal lawsuit, create a homegrown compliance program. Some resources:
- "Protect Your Practice With a Medicare and Medicaid Compliance Program" in the July-August 1998 Family Practice Management, at www.aafp.org/fpm.
- FP Assist, a network of consultants with profiles at www.aafp.org/fpassist.
- Medical Group Management Association, a Denver-based organization with resources for small group practices (online at www.mgma.com).
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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