Group Practice Administrators Use Coding Profiles to Describe What Physicians Do

ENGLEWOOD, Colo. -- Group practice administrators can benchmark physician coding behavior to evaluate similarities -- and differences -- between their physicians and other doctors in the same specialty. Three recent publications from the Medical Group Management Association (MGMA) using data from Physcape, Inc. reveal new details about physician coding patterns.

"By comparing the procedures that doctors perform to the largest national database describing patient care, a practice can evaluate potential miscoding of evaluation and management procedures, identify revenue opportunities, and judge if the physician mix is appropriate to the patient demand." said David Gans, MSHA, CMPE, director of the MGMA's practice management resources.

The three recently released Coding Profile Sourcebooks cover primary care specialties, medical specialties, and surgical specialties, pathology and radiology. The texts summarize more than 42.5 million procedures into coding profiles to provide administrators, medical directors and others with a comprehensive look at coding patterns never before available in this detail. The reports examine the most frequently performed procedures and diagnoses overall, and by patient age, category and gender for 31 provider specialties. Group practice managers, physicians, insurers and others can use the benchmark coding profiles to:

·Help identify possible undercoding and overcoding patterns, leading to greater revenue opportunity and decreased risk of fraud and abuse allegations;

·Assess compliance with Medicare regulations;

·Assess physician productivity, revenue opportunity and resource use based on the type and volume of procedures performed by a physician specialty.

MGMA's sourcebooks display data by diagnosis and physician specialty, allowing users to focus on physician response to specific scenarios.

"Until now, sources of coding profiles were limited to the Medicare data published by the Centers for Medicare & Medicaid Services (CMS). While those data are revealing, they are limited to procedures for care provided to patients over 65 and therefore are not an accurate measure across all patient populations and procedures," says Lisa Stavrakas, CPC, CPC-H, coding consultant for MGMA's Health Care Consulting Group. "As a consultant, I see abundant applications for these data to provide clients with profound and accurate coding analyses describing all of a physician's patients."

Analysis of physician activity by patient age and diagnosis provides documentation that supports popular knowledge regarding healthcare. Examples include:

·Differences in care for women and men: Female patients receive 60.1 percent of all hematology/oncology procedures and 71.8 percent of rheumatology procedures, while males receive 57.9 percent of invasive cardiology procedures. Nephrology procedures are distributed 49.6 percent to females and 50.4 percent to males.

·Patient demographics - Primary care physicians, overall, perform 23.8 percent of their procedures on pediatric patients and 24.1 percent on patients over 65 years. Medical specialties perform only 5.3 percent of their procedures on pediatric patients and 37.3 percent on patients older than 65 years.

·Common diagnoses - The three most frequently occurring diagnoses account for 47.3 percent of ophthalmology procedures and 36.3 percent of urology procedures, but only 14.3 percent of general surgery procedures.

MGMA's 2002 Coding Profile Sourcebook: Primary Care Specialties, 2002 Coding Profile Sourcebook: Surgical Specialties, Pathology and Radiology and 2002 Coding Profile Sourcebook: Medical Specialties describe 42,572,910 procedures performed by 10,909 providers and detail coding patterns across 31 provider specialties. Data were collected by Physcape into a national physician data repository. Complimentary copies of the reports are available to the press. Individuals interested in purchasing the MGMA 2002 coding profile sourcebooks should call (877) 275.6462, ext. 888.