The importance of ICD-9 codes on the mini-profile

Issue: BCMJ, Vol. 59, No. 5, June 2017, page(s) 271 Billing Tips
Lorne Verhulst, MD

If you receive fee-for-service (FFS) payments from the Medical Services Plan (MSP), a mini-profile will be generated, which is a statistical analysis of your billings for that calendar year.

The mini-profiles are made available by Doctors of BC to all physicians who have billed at least 1 year of FFS earnings to MSP. The profile gives you important information about your billings, and it tells you how your billings compare with other physicians in your peer group. If you are outside the statistical average, then you may find yourself in a situation where you would need to justify that difference.

The mini-profile enables you to take proactive steps to address any potential problems.

One way you can assess appropriateness of your total billings, as well as your use of resources (total patient costs), is by reviewing the “observed compared to expected ratio (O/E)” on your mini-profile. The observed costs are those incurred by the MSP for patients in your practice. The method for calculating expected costs uses the ACG (Adjusted Clinical Group) Case Mix System to determine the costs for these same patients if each was average for his or her ACG. The ACG system was developed in the US and is a widely used population-based health care tool. In BC, the ACG system was implemented in the profile in 2000, and it currently uses FFS diagnoses only—the International Classification of Diseases (ICD-9) diagnostic codes. The ratio of the observed to expected costs is used to compare your costs and use of services with that of your peers.

Since the ACG system relies on the ICD-9 diagnostic codes, it is important that you use the appropriate codes when billing MSP. If you enter only generic ICD-9 codes, your profile may reflect a lower morbidity score (i.e., patients would be incorrectly assigned to a lower-morbidity ACG), even though your patients may be sicker than those of your peers. (See “Hold it—my patients are sicker!” [BCMJ 2001;43:328-333].)

For example, if you submit ICD-9 code 780 for all your patients with asthma and yet they incur more costs due to this diagnosis, your patient population will appear no sicker than the average for your peer group—when in fact they are. It is expected that if your patients are sicker, they will incur more costs. This may help explain why your observed costs are higher than your expected costs.

You can check if you are using the appropriate ICD-9 codes when billing MSP on the government website at Providing accurate coding confirms your patient’s illness, which may be a benefit in the future.
—Lorne Verhulst, MD
Chair, Patterns of Practice Committee

This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board. For further information contact Juanita Grant, manager, audit and billing, Physician and External Affairs, at 604 638-2829 or