Variations in coding practices among Connecticut urologists for the Medicare population

Area of Science:

• Health Economics
• Medical Billing and Coding

Background:

• Rising healthcare costs necessitate exploring alternatives to fee-for-service physician reimbursement.
• A resource-based relative-value system was implemented to address Medicare reimbursement inequities.

Purpose of the Study:

• To analyze the coding habits of Connecticut urologists for evaluation and management (cognitive) services.
• To assess the consistency of Current Procedural Terminology (CPT-4) code utilization within a specific physician group.

Main Methods:

• Review of Medicare claims data for fiscal year 1986-87.
• Analysis of coding patterns for cognitive services filed by Connecticut urologists.

Main Results:

• Connecticut urologists predominantly use six CPT-4 code categories for cognitive services (99% of claims).
• Within these categories, an average of 82% of claims utilized a single primary code, but this code varied significantly between practices.
• Evidence suggests divergent standards in CPT-4 code application and fee schedule adjustments among urologists.

Conclusions:

• Connecticut urologists demonstrate inconsistent application of CPT-4 codes for cognitive services.
• Enhanced precision in CPT code definitions is crucial for adapting to relative-value-based reimbursement systems.