Medicare Compliance & Reimbursement

Use the latest benchmarking stats to see where your practice falls.

If a majority of your emergency department (ED) claims are reported with 99285, you may want to revisit your coding practices. Some EDs are billing this high-level code on over 80 percent of their claims, far exceeding the average.

That’s the word from a new comparative billing report (CBR) compiled by RELI Group Inc., with which the Centers for Medicare and Medicaid Services (CMS) contracts to develop, produce, and distribute CBR reports. The firm found that the average percentage of services billed to Medicare with 99285 (Emergency department visit for the evaluation and management of a patient...) was 46.53 percent. It’s a good idea for your practice to check out how many of your claims were billed with this code to see where you stand.

Read on to find out more on what the CBR uncovers.

Here’s What the Report Included

After the 2018 Medicare Fee-for-Service Supplemental Improper Payment Data Report showed an 11.3 percent projected improper payment rate, RELI was charged with evaluating the code utilization for these services, said RELI’s Annie Barnaby.

RELI then reviewed claims billed with emergency department service codes 99281-99285, in addition to the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) with the claim submission, and the average allowable charges submitted for this code set.

Remember: The feds use CBRs as a tool to offer insight into billing and coding trends across different specialties and healthcare settings. CMS partners with its contractor RELI to produce the reports, which you can find at www.cbrinfo.net. You can use data from the CBRs to see where you stand when it comes to the frequency of billing certain services, codes, or modifiers — and more importantly, utilize these peer measurements to eradicate your coding problems.

How the stats were found: To get the data for the CBR, RELI examined ED services billed to Medicare under the codes from the 99281-99285 range from over 138,000 providers for the year between Dec. 1, 2017, and Nov. 30, 2018.

Check out the Findings

When evaluating the percentage of services billed with 99285 (Emergency department visit for the evaluation and management of a patient...), the auditors found that the national average was 46.53 percent. However, that number varied wildly, with one provider billing 99285 on over 84 percent of claims, Barnaby said.

Keep in mind that if you do report 99285 more frequently than the average, it doesn’t necessarily mean you’re billing improperly. Billing patterns may differ for a wide variety of reasons — for instance, perhaps you practice in an underserved urban or rural area, or in areas with a higher proportion of sicker Medicare beneficiaries. However, if you do find that your ratio of 99285 claims is significantly higher than the average, it’s worth your time to perform a self-audit to find out whether all of these services were billed properly.

When it came to the use of modifier 25, RELI found that the national average was 10.44 percent, even though many providers had much lower and higher percentages of the modifier use.

The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M service were truly separate. With the EMTALA mandate in the ED and the fact that EDs deliver episodic acute unscheduled care to patients without a prior relationship, the modifier 25 requirements will generally be met.

Check that the necessary elements of the E/M service are all present and accounted for in your physician’s documentation. Ask yourself whether the documentation supports the level of history, exam, and medical decision making (MDM) being claimed with the E/M code being billed in addition to the procedure code.

As for the average allowed charges for all Medicare Part B services per visit, the national average was $126.93, although that number varied quite a bit from one provider to the next. You can see which states had the highest and lowest billings in “See If Your State Is in the Top Ranks” below.

Resource: For more on the findings of this comparative billing report, visit https://cbr.cbrpepper.org/About-CBR/CBR-201906.