Comparing Coding Patterns at Nurse Managed Centers: Data from a National Survey

Background: Nurse managed centers (NMCs) play an important role as safety net providers in the U.S., often caring for vulnerable populations. Yet, many NMCs struggle to succeed financially. Assessment of Current Procedural Terminology (CPT) coding patterns is a key strategy to support long-term sustainability. Purpose: To compare coding patterns of nurse practitioners (NPs) in NMCs delivering primary care with the Centers for Medicare and Medicaid Services' (CMS) data of NPs and family physicians (FPs). Framework: CMS guidelines use CPT codes to document services provided and to determine reimbursement for professional healthcare services. For office visit codes, higher code numbers indicate higher levels (1 through 5) of service intensity (and reimbursement). Design: A descriptive, retrospective study to develop a national NMC database and to identify NMC benchmarks. Subjects: 13 centers reported CPT data. Centers represented diverse locations, populations, and funding sources. Method: A standardized survey was distributed via email to 122 NMCs listed in a national directory. Of 42 NMCs that responded, 30 participated and completed surveys. NMCs were asked to submit a list of all CPT codes, other financial data, and center characteristics for year 2004/2005. Frequency distributions and ratios of CPT codes were compared across NMCs and with national data, focusing on Evaluation and Management (E&M) codes for ambulatory care visits. Interviews were conducted with center representatives to more fully understand the (mis)match between findings and a center's population served. Results: Among NMCs, the distribution of new patient visit codes showed markedly high utilization of codes representing less intensive services. For established patient visit codes, the distribution was closer to a normal curve, yet continued to show higher utilization of codes representing less intensive services. Compared to CMS data, while NMC data were more similar to NP data, NMC data consistently showed higher use of less intensive services than either NPs or FPs in non NMC sites. Examination of distributions of many individual NMCs found little to no use of higher intensity services suggesting undercoding. Discussion: Reasons for coding variations among national data and among centers are described. Implications for education, practice, research, and policy are discussed.