Coding multiple diagnoses for patient visits at which procedures were performed: no evidence for abuse by physicians.

Background: A problem area in the reimbursement of physicians is the office visit at which both procedures and evaluation/management services are performed. Insurers are concerned that frequent reporting of diagnoses unrelated to procedures may represent an abuse of the claims process.

Objective: To determine the frequency of secondary diagnoses that are present at visits at which procedures are performed and to compare the frequency with that reported in Medicare claims.

Method: The 1998 and 1999 National Ambulatory Medical Care Survey (NAMCS) data were used to provide data unrelated to claims for payment. The results were compared with Medicare claims data from the 1998 to 1999 Medicare Current Beneficiary Survey. NAMCS visits were limited to patients who were 65 year old or greater to limit the analysis to the Medicare population.

Results: In the NAMCS dataset, 52% of the visits for actinic keratoses at which a procedure was performed were associated with multiple diagnoses. Similarly, in the Medicare Current Beneficiary Survey dataset, 52% of these visits had multiple diagnoses listed.

Conclusion: The frequency of visits with multiple diagnoses is the same in both administrative claims and epidemiologic survey databases. There is no evidence for widespread abusive coding by physicians. It is incumbent on payers to respect the integrity of the coding system in order to assure fair reimbursement for physician services.