CPT fee differentials and visit upcoding under Medicare Part B.

Area of Science:

• Health Economics
• Medical Billing and Coding

Background:

• Medicare Part B reimburses outpatient physicians using Current Procedural Terminology (CPT) codes.
• Discrepancies in procedure and intensity between CPT codes create incentives for physicians to upcode services.
• Upcoding can increase the profitability of patient visits.

Purpose of the Study:

• To investigate the impact of Medicare Part B fee differentials on the upcoding of general office visits (CPT codes 99212-99215).

Main Methods:

• Analysis of nationally representative data from the 2001-2003 Medicare Current Beneficiary Survey.
• Examination of physician coding choices in response to fee differentials across various specialties.

Main Results:

• Strong evidence indicates that Medicare Part B fee differentials significantly influence physicians' coding decisions for billing.
• Upcoding of general office visits may account for up to 15% of total Medicare expenditures for these services.

Conclusions:

• Clarifying Medicare's classification rules presents a significant financial opportunity for the program.
• Ambiguity in visit distinctions under Medicare Part B likely perpetuates the practice of upcoding.