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POSTS BY TAG | Medical Billers

Overview of Comparative Billing Reports

 

In 2010 the Centers for Medicare and Medicaid Services (CMS) began to release Comparative Billing Reports (CBRs). A CBR compares provider to provider billing practices, both regionally and nationally, to determine if a provider is an “outlier”, or billing outside of the expected pattern. If a provider is found to be an outlier, they will receive a notification detailing the analysis and erroneous billing, while offering education on the topic. CBRs review many areas of billing, and even topics outside of billing. Some common topics include; evaluation and management, modifier utilization, and groups of specific codes, for example, radiation modality treatments for oncology providers or dialysis visits for nephrology providers. It's also important to note that CMS is not the only one reviewing billing practices in this manner. Other large commercial payers have similar programs, such as UnitedHealthcare’s Peer Comparison Reports, which functions much like the CBR.

What is a CBR used for?


CMS and other payers perform CBRs and similar reports with the goal of providing educational resources and outreach. This outreach ensures compliance with coding and billing standards and reduces potential fraud, waste, and abuse. CBRs can also ultimately help patients. Most patients are unaware of the many coding and billing rules that exist and therefore have a difficult time identifying when they have been overcharged. This can lead to costly out-of-pocket expenses toward co-insurance and deductibles. Educating providers can offer a real impact on reducing a patient’s financial burden.

What should I do if I received a CBR?


While CMS says “receiving a CBR is not an indication of or precursor to an audit” the receipt of a CBR can still be a stressor, especially if a provider or practice does not have the right tools to internally investigate the CBR findings, or worse, does not know where to begin to address a CBR. The risk of removing focus from the patient care to address these billing practices is high. Additionally, ignoring the report altogether could place the provider and practice at risk for more CBRs in the future and even potential audits. CBRs should be promptly reviewed and addressed by taking the following steps:

* Examine the issue identified in the report closely
* Evaluate the organizations or individuals billing patterns as they relate  to the CBR subject
* Perform a root cause analysis and address or correct any errors with education
* Continue to monitor the situation closely

How do I avoid a CBR?


One of the best defenses for CBRs and other billing challenges is to practice proactive risk analysis, or regular and consistent monitoring to identify potential billing issues before they begin. Proactive risk analysis can easily be achieved by utilizing the data that already exists within your billing software. Reports that visually display information such as charge capture counts or evaluation and management level distribution can be particularly useful. The same reports can then be combined with CMS benchmarking data, allowing a provider or practice to easily identify any variance from expected billing patterns.

These reports should paint a clear and visible picture, providing valuable insight. In the event a CBR is received the reporting can be used as part of the examination and subsequent monitoring following education on the error. Reports can also be supplied to coding/auditing or Clinical Documentation Improvement Departments as a resource to begin analysis for targeted internal education.

Taking a proactive approach to billing patterns can effectively decrease billing errors, support operational excellence and allow providers to spend more time focusing on patient care, which is the heart of pMD’s mission.

If you are interested in learning more about pMD’s Billing & Revenue Cycle Management Services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you!

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.

 


Welcome to the "Biller’s Corner" of the pMD blog, your trusted source for updates, tips, and tricks provided by seasoned medical billing and coding experts!

Medical coding is often a moving target, especially during a pandemic. But have no fear, we’re here to provide guidance on some recent coding updates you need to know about!

NEW COVID-19 VACCINATION CODE ALERT



Speaking of the pandemic, the AMA recently released the CPT® code 91303 for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, for intramuscular use.

Here’s what you need to know:

* This is the code used for the one-dose COVID-19 vaccine developed by Janssen Pharmaceutica, a division of Johnson & Johnson.


* It should be used in conjunction with the CPT code 0031A, Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative-free, 5×1010 viral particles/0.5mL dosage, single dose.


AMA PROVIDES ADDITIONAL CLARITY ON THE UPDATED E/M CODE SET



Another hot topic this year has been the significant updates to E/M office codes (99201-99215). The primary intention behind the changes is to reduce the administrative burden of unnecessary documentation, in turn, allowing for more time to interact with patients. While the intention is great, there has been a lot of confusion surrounding the revisions made to this code set, and many physicians have reported that the ambiguity of the new revisions is actually leading to additional time spent on documenting. This is obviously the opposite of what they were going for, so the AMA is acting on that feedback and has released the following revisions, retroactive to January 1, 2021.

TIME-BASED BILLING

For time-based billing, you should not account the following:

* Performance of other services when reported separately


* Travel time


* Teaching that is not required for the management of the specific patients' care


Also, remember Medicare and private payers’ policies can differ when it comes to reporting prolonged services for time-based billing. Although the AMA has established the CPT 99417,  Medicare has assigned a status indicator of “I” for this code which denotes the code as invalid. Instead, Medicare will accept HCPCS code G2212 when reporting 15 minutes of prolonged care, performed on the same encounter as E/M codes 99205 and 99215. When billing for either code, be sure that it is listed separately in addition to a level 5 office/outpatient E/M service.

MEDICAL DECISION MAKING

When it comes to medical decision making (MDM), you should account for tests that are analyzed as part of MDM and are not reported separately when interpreting the study. These may be counted as ordered or reviewed when selecting an MDM level.  When determining the complexity of problems and the number of problems addressed, also consider the following:

* If the presenting symptoms are likely to represent a highly morbid condition, this may “drive” MDM even when the ultimate diagnosis is not highly morbid. Multiple low severity conditions may equate to a higher risk level due to interaction.


* When determining data reviewed and analyzed, pulse oximetry is not considered a test.


* When considering data elements reviewed, a combination of three data elements can be counted by reporting a unique test ordered, plus a note reviewed and an independent historian. However, it does not require each item type or category to be represented.


* Ordering a test may include those considered, but not selected after shared decision making due to patient health risk or a discussion to forego further testing due to lack of medical necessity.


UNDERSTANDING THE KEY TERMINOLOGY

The AMA has also provided clearer instructions to interpret the definitions that make up the elements of MDM. Understanding the following terms as they are laid out by the AMA is crucial:

* Analyzed: Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.


* Discussion:  Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). The discussion can be asynchronous and occur on a later date following the encounter but must be completed within a short time period (eg, within a day or two).


* Independent Historian: When collecting the history, it does not need to be obtained in person but does need to be obtained directly from the historian providing the information.


* Risk: The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.


* Surgery (minor or major): The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. Be advised that CPT guidelines indicate that it is the provider's clinical determination whether surgery is considered major or minor and is not dictated by global days. However, if the surgery occurs in an office setting, you will have a hard time justifying it as a major surgery. Major surgeries will most often require the use of an operating room.


* Surgery (elective or emergency): Elective procedures and emergent or urgent procedures describe the timing of a procedure as it relates to the patient’s condition. An elective procedure is typically planned in advance and scheduled, while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures. 


* Surgery (risk factors): Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.


A full list of revisions can be found on the AMA website. Plus, be on the lookout for even more revisions that will become effective in 2023. 

Make sure to check back in soon for more billing and coding updates! And if you are interested in learning more about pMD’s billing and revenue cycle management services, please contact us here or give us a call at 800-587-4989 x2. We’d love to hear from you! 

To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.