Proprietary CPT utilization analysis benchmarked against the OIG 2026 Work Plan and published specialty norms. Surfaces dollar-quantified findings across E/M leveling, modifier patterns, and high-risk procedure codes — delivered as a 12-page PDF and 9-tab Excel within 5 business days.
The CPT Utilization Snapshot is not a chart audit. It is a statistical analysis of your claims data — how your CPT utilization distribution compares to published specialty norms, where your patterns overlap with the OIG 2026 Work Plan's 58 tracked audit priorities, and what dollar exposure those overlaps carry.
Most practices have no idea whether their E/M level distribution is above or below their specialty peer group. They don't know whether their modifier 25 frequency matches their documentation volume. They don't know which of their top-20 CPT codes are on the OIG's active watch list this year. This report answers all three questions — before an auditor does.
Every CPT code in your claims data is cross-referenced against the 58 items tracked in the OIG 2026 Work Plan. Hits are flagged with the specific OIG work plan item, the audit rationale, and historical overpayment rates from prior OIG reports.
Your E/M level distribution (99202–99215) is compared against published specialty benchmarks. Modifier 25, 59, and bilateral modifiers are analyzed for same-day frequency patterns that trigger NCCI edits and OIG scrutiny.
Every finding is accompanied by a dollar exposure estimate — calculated from your actual claim volume and CMS fee schedule rates. The aggregate exposure figure in the executive summary is the number your compliance officer needs for a board presentation.
For multi-provider practices, findings are broken out by individual provider — identifying whether a pattern is practice-wide or attributable to a specific billing profile. Critical for distinguishing a documentation training issue from a systematic billing error.
The OIG updates its Work Plan continuously. We track all 58 current items; 37 have direct CPT billing implications that can be detected in claims data. Your snapshot is benchmarked against the current list at the time of your engagement.
OIG audits of 99215 and new patient high-level E/M codes remain active across all specialties. Level 5 frequency above specialty norm is the single highest-risk pattern in primary care and internal medicine claims data.
OIG's 2025 report on modifier 25 found significant overpayment rates when E/M visits are billed same-day with minor procedures. Frequency above 30% of procedure days is a documented audit trigger.
Annual Wellness Visit billing (G0438, G0439) is a recurring OIG audit target. Documentation compliance — personalized prevention plan, health risk assessment completion — is required for every billed AWV claim.
E/M level distribution, AWV documentation patterns, and modifier 25 frequency are the three highest-risk coding patterns in primary care. This snapshot is calibrated for exactly this billing profile — and will surface the most findings per dollar spent at any primary care practice over 1 provider.
Surgical specialties with high modifier volume, mental health practices billing 90837 and 90834, and any specialist with significant E/M volume alongside procedure codes benefit from the modifier and E/M distribution analysis. OIG Work Plan items vary by specialty — the engine adjusts.
The provider-level breakout tab is the primary value driver for groups. A practice-wide pattern that is actually driven by one provider's billing behavior looks very different from a systematic coding error — and requires a different corrective action. The breakout tells you which it is.
Medspas billing any Medicare-reimbursable services — botulinum toxin for medical indications, laser procedures, wound care — can use the Snapshot to surface OIG exposure on those specific CPTs without a full coding audit.
A new owner or management team inherits the prior operation's billing patterns. The Snapshot is the fastest way to understand what you acquired from a coding risk perspective before the first OIG audit cycle reaches the prior operator's claims.
If the last coding review was more than 18 months ago — or never — the statistical analysis surfaces pattern-level risk faster than a chart audit and costs a fraction of the price. Use the Snapshot to decide whether a full audit is warranted and where to focus it.
Submit your claims data (CSV format, up to 12 months) and we'll return the 12-page PDF and 9-tab Excel within 5 business days. No PHI required — aggregate CPT-level claims data is sufficient for the full analysis.
Or email hello@prognosisconsulting.com · Data submission instructions sent within 1 business day