Article

Coding

Do code “trends” exist?

If so, how can you use these trends to benefit your practice?

A recent reader of this column asked me “how often” certain codes can or should be considered for billing. I directed the reader to a recent Coding column (tinyurl.com/Coding117 ) then was asked where the information came from and what it might mean. The thrust of the reader question was about data and how to track it.

As a result, this issue’s column grew from timely new information from the Centers for Medicare & Medicaid Services (CMS) about the 2016 claims data for Part B Medicare. The information is found in the 2016 data on how often doctors billed certain exams, diagnostic tests, and surgeries in eye care. Perhaps most importantly to the reader, by viewing the previous years’ data, we can see if “coding trends” do exist. Looking even further back, we can gain a real historical perspective. Payers can track this data and target for review and scrutiny those codes that show growth — especially if they are skeptical or unaware of how eye doctors use the new technology.

Examine the trends

Many technicians already watch certain things in your offices by “how many times” it happens. You might watch how many patients you see both daily and weekly/monthly, and perhaps you (along with your payers and some of your billing staff) watch different metrics.

CMS makes a large database of physician claims information available for purchase every year,1 which you can compare to prior year information to establish both long-term and shortterm trends. CMS is careful to note: “Of particular importance is the fact that the data may not be representative of a physician’s entire practice as it only includes information on Medicare fee-for-service beneficiaries. In addition, the data are not intended to indicate the quality of care provided and are not risk-adjusted to account for differences in underlying severity of disease of patient populations.”

Even with those limitations, such as not having Medicare-age data for those enrolled in Medicare Part C (Medicare Advantage, or MA), this information can be very valuable; if your patients are on Medicare, you can compare this with your own practice data and could even graph it if you were so inclined.

Common exam data

Table 1 (page 30) shows the newest 2016 Medicare Part B information for some of the more common exams done by ophthalmologists.

Table 1. Claims data for Part B Medicare
CPT Code(s) Descriptor 2016 2015 Difference % change
99205 Level 5 E/M, New 42,224 51,418 (9,194) -17.9 %
99215 Level 5 E/M, Established 116, 875 126,833 (9,958) -7.9%
92004 Comp Eye Exam, New 1,317,891 1,324,599 (18,505) -1.2%
92014 Comp Eye Exam, Established 8,672,170 8,538,498 (133,672) +1.6%
99214 Level 4 E/M, Established 1,351,329 1,423,755 (72,426) -5.1%
99213 Level 3 E/M, Established 2,083,082 2,205,941 (122,859) -5.6%
92012 Intermediate Eye exam, Established 5,492,799 5,445,110 47,689 +0.9%

You can see that the frequency of exams billed to Medicare on most exam codes decreased in 2016 compared to the prior year. Your general sense might be that exams are trending downwards, but this ignores the fact that not all exams are billed to Medicare — some go to MA and many to private payers. It’s certain that enrollment in MA is growing at the expense of Part B even though it’s lower at this time.2 You may see it yourself; perhaps your office has gotten involved with a new MA plan in 2016 and that’s where the patients (and now bills) are. That’s an important piece and shows that you can’t use this trend alone to make every decision.

Other trends

Table 2 (page 30) is a limited sampling of some other 2016 data on diagnostic tests, modifiers, and surgeries.

Table 2. Frequency of other notable claims
CPT Code(s) Descriptor 2016 2015 Difference % change
66984 + 66982 Cat Extraction w/ IOL, Complex Cat w/ IOL 1,859,152 1,813,827 45,325 +2.5%
15823 Blepharoplasty 83,537 83,240 297 0%
66821 YAG Capsulotomy 646,531 630,112 16,419 +2.65
67028 Intravitreal Injection 3,215,435 2,959,021 256,414 +8.7%
-25 Modifier 25 2,461,077 1,896,689 564,388 +29.8%
MIGS3 Variety of codes 48,126 34,970 13,156 +37.6%
76514 Corneal Pachymetry 599,294 353,036 246,258 +69.8%
95004 Allergy Testing 487,020 638,135 (151,115) -23.7%
3. MIGs includes the following five codes: 0191T, 66174, 66175, 66183, 0253T

Some “trends” readily stand out. Cataract surgery grew slightly, while blepharoplasty stayed flat. Claims to Part B Medicare for modifier 25 use, Minimally Invasive Glaucoma Surgery (MIGS), and corneal pachymetry grew at very high rates. Allergy testing showed a dramatic decrease. As mentioned, payers are likely to be looking at codes that either already have high use or are growing faster than the overall growth of the population affected.

Conclusion

“Code trends” do exist. Code usage goes up and down for many reasons. Knowing the trends enables you to take a critical look at your office’s use and be ready for the inevitable records requests that follow when codes are expensive, growing quickly, or both. Payers will use the data — you should too. As the Boys Scouts say, “Be prepared.” Check your applicable payer guidelines and your office documentation to ensure that the requests you get are easily defended in case they are questioned.

Lastly, if you’d like me to address certain coding questions or topics, OP is happy to listen — some of my best columns have come from readers’ suggestions.

As always, “good coding to you.” OP

REFERENCES

  1. MS. Medicare Provider Utilization and Payment Data: Physician and Other Supplier. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html . Accessed October 9, 2017.
  2. MS. Medicare Enrollment Dashboard. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/Dashboard.html . Accessed October 9, 2017.