Medicare offers data for comparing billing patterns

Track CPT coding trends

A relatively fast way to compare how the codes you most frequently use compare to the national average for other practices is to access Medicare’s Part B billing data. These data on physicians’ services and specialty-specific procedure code utilization are available for free on the Internet.

"This will permit you to view the number of times your specialty billed each Current Procedural Terminology [CPT] code. Using this information and a few simple calculations, you can determine the frequency with which your specialty billed Medicare for a particular CPT code within its family of codes," notes Brent Baker, a reimbursement specialist with the American College of Physicians-American Society of Internal Medicine (ACP-ASIM).

Follow these instructions from Baker, and you’ll be able to use Medicare’s on-line database to find out the frequency and distribution of your specialty’s billing of specific CPT codes. For instance, you can find the frequency and distribution of internists’ billing of established patient office visit codes. You can also use these figures, which represent national billing patterns, as a general guide when assessing your own billing patterns. Medicare carriers, for instance, use these physician billing profiles to find billing patterns outside the norm so they can flag practices for possible investigation.

Here’s how to get started with your computer search:

  • Create a folder on your C: drive, name it "Specialty Utilization," and note the folder’s location.
  • Go to the Centers for Medicare and Medicaid Services (CMS) Internet home page at www.cms.gov.
  • Click on the "Stats and Data" box in the left-hand column of the site’s main page, which contains the "Welcome to" heading.
  • Click on "Resource Based Practice Expense Data Files" under the "Information Clearinghouse" heading.
  • Click on "Procedure Code Utilization by Specialty" under the "Interim Resource Based Practice Expense Data Files" heading.
  • You will be prompted to save the database file to your hard drive; click on the "yes" button and save the file in the "Specialty Utilization" folder you created on your C: drive. Once the file has been saved, exit your Internet browser.
  • Go to your C: drive and open the "Specialty Utilization" folder. You will find a file named "Specutil.exe" double-click on this file. A window will appear telling you that three files are being decompressed and deposited into your "Specialty Utilization" folder. The window will disappear once the files have been decompressed.
  • Go to your "Specialty Utilization" folder. In addition to the Specutil.exe file (which you can now discard), there should be four other files. Look for the file named "Specutil.mdb" and open it in Microsoft Access or another database program. If you have a recent version of Access, you will be prompted to convert or open the file; choose to convert the file. You will then be prompted to save the file; save it in your "Specialty Utilization" folder and assign it a new file name.
  • A box will appear asking you to acknowledge the AMA’s copyright; click on the "OK" button.
  • In Microsoft Access, you will see three tables:

Table 1 provides a note on non-facility PE-RVU; disregard this information.

Table 2 is a specialty code description table that lists all the specialty designation codes. For example, the specialty designation code for internal medicine is "11" and the code for rheumatology is "66." You will use the two-digit number for your specialty to locate the relevant data in the utilization database.

Table 3 is a utilization table that contains utilization data per code for each specialty. The table, which contains a massive amount of information, has headings of: CPT (HCPCS) code; modifier, HCFA specialty code; facility indicator; and allowed service.

Follow these steps to determine the frequency and distribution of billings for a family of codes:

  1. Select a family of codes.
  2. Find the appropriate specialty code and total the "allowed service" column for each individual CPT code. Note: A single specialty may have more than one allowed service number for a single CPT code because of modifiers.
  3. Add the allowed services for each CPT code to arrive at the total for the specialty for a family of codes.
  4. Divide the total allowed services for each individual CPT code by the total allowed services for the family of codes to arrive at a percentage for each individual code. The percentage for each code signifies the frequency with which it is billed compared to the other levels of service within its family of codes.