Check frequency, relationships among codes in statistical profile

Why This Topic Matters

Utilization profiling can help practices spot unusual billing patterns, evaluate whether coding aligns with documentation, and determine whether comparisons are being made against the correct peer group. The article also frames the profile as a tool for internal review, education, and response planning when discrepancies are found.

Article Sections

1. Using utilization profiles in practice review

   Introduces the use of practice utilization profiles as a way to review billing patterns and compare them with external benchmarks. Discusses how these reports may be obtained and why practices use them.

2. Comparing coding patterns and peer-group relationships

   Explains how to examine frequency patterns and relationships among evaluation and management services within a specialty. Focuses on peer comparisons, variation analysis, and identifying potential outliers.

3. Reviewing pricing, payment, and carrier analysis

   Describes how the profile can be used to review fee schedules, payment amounts, and carrier analysis for consistency with actual billing. Also addresses the importance of correct peer-group classification.

4. Responding to problems found in the profile

   Covers general next steps when the review suggests overcoding or undercoding, including legal review, restitution considerations, and internal compliance efforts. Emphasizes using the findings for education and corrective review.