Medicare Compliance & Reimbursement

Find out where your code usage fits into the stats.

If you worry that your claims aren’t on par with other practices, you’re not alone. Comparative Billing Reports (CBRs) allow you to check your numbers, ensuring your practice claims are in line with federal standards — and in step with your peers. In a new release, CMS focuses on the perennial issues family practitioners have with E/M office visits to help you figure out where you stand.

Background: In 2018, CMS merged its CBR program with the Program for Evaluating Payment Pattern Electronic Reports (PEPPER) programs. Previously, Medicare Administrative Contractor (MAC) Palmetto GBA facilitated CBRs with its partner, consulting firm eGlobalTech.

Now, RELI Group and its partners — TMF Health Quality Institute and CGS — construct CBRs and PEPPERs for CMS, notes CBR guidance. Under this new management, the agency released CBR 201902 on Feb. 28, homing in on claims issues with E/M office visit codes (99201-99215) for family practitioners (specialty code 08).

Reminder: The feds use CBRs as a tool to offer insight into billing and coding trends across different specialties and healthcare settings. More importantly, the specialty comparisons allow Medicare providers to see how their claims match up against others in their states and across the nation in order to eradicate incorrect coding and circumvent outlier tendencies. Plus, the timely data lets you see where you stand when it comes to the frequency of billing certain services, codes, or modifiers, too.

Important: “At this time, RELI Group, Inc., does not post or create content in conjunction with MACs, although this may be implemented in the future,” the question-and-answer section of CBR 201902 mentions.

Review the CBR Details

CBR 201902 utilized the information of 80,636 “rendering providers” — under the family practice specialty — “who submitted claims to Medicare Part B for new and established patient visits (CPT^® codes 99201–99205 [Office or other outpatient visit for the evaluation and management of a new patient …] and 99211–99215 [Office or other outpatient visit for the evaluation and management of an established patient ...])” between Oct. 1, 2017 and Sept. 30th, 2018, indicate the CBR materials.

“More specifically, the CBR analyzed claims submitted with codes 92204, 99205, 99214 and 99215, so levels four and five of the newly established patient code, and the relationship to those codes as compared to the submission of all new and established patient E/M codes,” explains the RELI Group’s Annie Barnaby in the CBR webinar.

Here’s why: According to the 2018 Medicare Fee-for-Service Supplemental Improper Payment Data Report, commonly referred to as the Comprehensive Error Rate Testing (CERT) report, more than $1 billion in projected improper payments are attributed to these E/M office visit codes, due mainly to incorrect coding.

“Looking even closer at the projected improper payments for both new and established patient encounters, we can see 86 percent for new patients and 66.4 percent of projected improper payments for established patients were due to incorrect coding,” Barnaby says.

More importantly, CMS’s reasoning for focusing on family practitioners relates to their substantial impact on the overall improper payment rate, issues they have with incorrectly coding these services, and problems with submitting adequate documentation to back up higher-level codes.

The CERT data revealed that these specialists added 13 percent to the error rate with $727 million in improper payments. “Obviously that’s a very large number, especially when you think about this is only one specialty, family practice,” Barnaby adds. Plus, 27.5 percent of improper payments for E/M office codes by family practitioners were due to incorrect coding while 61.7 percent were attributed to insufficient documentation, the CBR materials note.

Check Your Numbers

RELI Group “drilled down” on family practices’ use of the E/M level four and five codes specifically “to look at the improper payment rate and where the outliers might live,” says Barnaby. The CBR highlighted four possible E/M claims outcomes that providers fell into compared to their state and national peers: significantly higher; higher; does not exceed averages; and not applicable due to insufficient findings.

Providers received a CBR from RELI Group if they met all these criteria:

• Submitted more than 50 beneficiary claims for either 99201-99205 or 99211-99215.
• Ranked greater than the 90th percentile (significantly higher) in one of the 12 metrics.
• Had at a minimum $10,000 in allowed charges for the aforementioned codes over the time period.

Tip: RELI Group offers a variety of formulas and a sample CBR that helps interested providers determine their claims positions. For example, to figure out your average allowed amount for established patients using CPT^® code 99215, the CBR advises to divide your allowed amounts of 99215 by all your allowed charges of 99211-99215.

“It is important to always remember that receiving a CBR is not an in any way an indication of, or a precursor to an audit,” counsels Barnaby.

Resource: For a more in-depth review of the CBR materials, visit https://cbr.cbrpepper.org/About-CBR/CBR-201902.