Lost in a Pile of NumbersAre Your Doctors Who They Say They Are? Lost in a Pile of NumbersAre Your Doctors Who They Say They Are?

Lost in a Pile of Numbers Are Your Doctors Who They Say They Are?

Frank Cohen, MPA, MPB

This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

As many might know, one of my primary projects is predicting the likelihood that a particular provider may be audited and if so, which procedures codes and/or modifiers are most at risk. To a large degree, the type of target acquisition conducted by government and private payers relies upon a core benchmark of peer-based utilization, and while that may not be the entire story, it is the introduction for sure. This initial benchmark is conducted based on the specialty of the provider being reviewed, so it would stand to reason under the GIGO (garbage in, garbage out) assumption that if the specialty is wrong, then everything that follows is wrong as well.

For example, let’s say I have a physician who is practicing as a cardiologist. The organization lists him/her as a cardiologist, s/he is promoted as a cardiologist and the billing is done under the guise of a cardiologist. This cardiologist is billing for a ton of procedure codes (CPT 99234, 99235 and 99236 for pacemaker interrogation services). In fact, let’s say that these are the first, second and third-most often reported procedures, respectively, by this cardiologist.

As a result, this cardiologist gets selected for an audit because based on Medicare peer utilization data that shows these procedures are ranked 28th, 26th and 25th, respectively for the average cardiologist. In fact, nationwide these procedures account for about 1.5% of all procedures reported by a cardiologist.

But wait! Let’s say that, instead of a cardiologist, this physician is actually a cardiac electrophysiologist. Now, the picture is much different because for that specialty, those three codes are ranked as the 8th, 5th and 4th most often reported codes with a total distribution of just over 14%, or over nine times as often. That makes a huge difference because when compared against other cardiologists, this provider looks like an anomaly, but when compared to other cardiac electrophysiologists, the provider looks normal. I could give you dozens of examples where this is not just a theoretical problem but has caused real-life problems for many physicians and practices.

So, who cares, really? Well, you should, because the payers do. Where do you think the benchmark data comes from? They might be from the national Medicare fee schedule database or the national Medicare claims database or some private payer database, but no matter the source, they are all basing their benchmarking decisions on provider specialty. The specialties come from one of two places: the NPPES database or the PECOS database, and sometimes it’s a crapshoot to know who uses which database.

For example, in conversations with folks who conduct the annual CERT (Comprehensive Error Rate Testing) study, I was told that they rely on the NPPES database. But for determining anomalies under the FPS (fraud prevention system), the specialties are determined using the PECOS database. The MACs tend to rely on the PECOS database while I have heard that private payers rely more on the NPPES database.

So, what’s a physician to do? The first step is to take a look at each of these and ensure that the physician’s specialty is properly registered. For the NPPES database, go to https://npiregistry.cms.hhs.gov/ and type in the NPI number. There are instructions that explain how to update the physician’s primary as well as secondary taxonomy codes. For the PECOS database, go to https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 and follow the online instructions.

I can tell you that, based on the tens of thousands of physicians for whom I have conducted risk assessments, just over 10% have been registered under the wrong specialty in one or both of those databases, resulting in audits – expensive, resource-intensive audits – that should have never occurred. It’s not just a small error; I have seen cases where physicians were registered as one specialty under PECOS and a different specialty under NPPES, but their actual specialty was different from both. Such cases make it very confusing when trying to understand why a provider is being subjected to an external audit.

You know the old expression: “Fool me once, shame on you; fool me twice, shame on me.” I can’t think of a better application of it than this.

This Week’s Audit Tip Written By:


Frank Cohen, MPA, MPB

Frank Cohen is the Director of Analytics and Business Intelligence for our parent organization, DoctorsManagement.

What to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email info@drsmgmt.com.
  2. Read more: What can you expect from a coding and compliance review?
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