How to Use Comparative Billing Reports as an Educational Tool

Improve your billing practices and avoid compliance issues by
utilizing this Medicare program.

The Centers for Medicare & Medicaid Services (CMS) initiated the Comparative Billing Report (CBR) program in 2010 to evaluate claims submission data, develop provider education, and raise awareness of peer-to-peer billing patterns. CBRs are unique to a specific provider and can be used as a free educational resource and tool for possible billing improvements. Even the most compliant billing process can benefit from this sort of analysis. In this article, we’ll explain the review process and look at the latest CBRs for 2022.

What Is a CBR?

CBRs are designed to protect the Medicare Trust Fund by focusing on areas that may be vulnerable to compliance, billing, and/or coding issues. To this end, a CBR team works to identify clinical areas with the potential to significantly affect the Medicare Trust Fund, analyzes claims data associated with those areas, and generates individualized CBRs for providers.

The report compares providers on a state, specialty, and/or national level and summarizes Medicare claims data statistics in areas that may be at risk for improper Medicare Part B payments. While a CBR cannot identify improper payments, it can alert providers if their billing statistics look unusual as compared to their peers.

A CBR is presented to a provider when the analysis of their billing patterns differs from their peers. The analysis of a provider’s billing patterns is completed by assessing CBR topic metrics and their potential risk to the Medicare Trust Fund.

How Are CBR Topics Selected?

Working with CMS, the CBR team identifies CBR topics by gauging the vulnerability of Medicare Part B claims billing for errors, as well as the potential educational value to providers and administrative billing staff. The selection of each topic for analysis is a detailed process involving resource research and data analytics. This process begins with an analysis of nationwide claim submissions, after which the CBR team examines the results in conjunction with relevant coding guidelines and Medicare payment policies. The CBR team uses these shared analyses to confirm that a topic will provide useful information and education. CMS oversees the creation of the CBR and supporting resources and holds final approval for all selected topics.

How Are CBRs Created?

CBRs include five detailed sections that explain all facets of the CBR topic:

The Introduction section contains:

• An explanation of the CBR focus
• The CBR analysis timeline
• An expectation of provider behavior regarding billing and coding
• The vulnerability of the CBR topic, according to improper payment rates
• The criteria for receipt of a CBR

The Coverage and Documentation Overview section identifies:

• The CPT®, ICD-10-CM and/or HCPCS Level II codes used in the report analyses
• A summary of the provider’s utilization related to charges, units, and beneficiary count pertaining to the topic.

The Metrics section describes:

• The metrics included within the report
• The peer group definitions (usually the nation and the provider’s state) used to identify outliers for CBR receipt using metric comparisons

The Methods and Results section presents:

• A national-level and state or specialty summary of the number of providers included in the analysis and the overall claims submission volume for the topic
• An explanation of the calculation for each metric
• The individual provider’s results for each metric
• The comparison of the provider’s outcomes to each peer group for each specific metric

There is also a References and Resources section for complete transparency.

Who Receives a CBR?

The CBR team determines the criteria for receiving a CBR for each release. A CBR is presented to a provider when the analysis of their billing patterns differs from the provider’s peers.

Receiving a CBR is not an indication of, or precursor to, an audit. A CBR is not an indication of wrongdoing; the CBR is educational in nature and should be reviewed as such. Receipt of a CBR is not a prompt to make changes to your clinical care. The report is merely a comparison tool and is not a suggestion of services that should be provided to patients. Receipt of a CBR does not necessitate a response — it is meant for internal use.

Even if a provider does not receive a CBR, staying abreast of areas of vulnerabilities is an important part of an internal compliance program. For every CBR release, public resources are available, including a sample CBR, the data used in the analysis, a webinar recording, slides and transcript, a guidance and considerations document, and a Q&A document.

How Are CBRs Distributed?

A provider is issued a CBR by email or fax and through the mail. These communications are distributed to the contact information that is listed in the Medicare Provider Enrollment, Chain, and Ownership system (PECOS). Providers are encouraged to log in to PECOS each year to confirm or update their information. The alerts contain a verification code, which is used to download the CBR through a secure online portal, located at cbrfile.cbrpepper.org. Providers are encouraged to download their CBR to be saved as a PDF file for reference during future annual internal compliance reviews.

Recent CBR Releases

CBR topics for 2022 included billing for certain services in chiropractic, podiatry, allergy and immunology, ambulance, laboratory, and ophthalmology.

Chiropractic Manipulative Treatment of the Spine

Vulnerability:

Chiropractic services carry an improper payment rate of 33.7 percent, which represents $176,774,349 in possible improper payments. An 86.8 percent improper payment rate is attributed to insufficient documentation and an 8.6 percent improper payment rate is attributed to medical necessity errors.

After review of and research into the improper payment rate, this CBR was created to analyze the possible threat associated with chiropractic services to the Medicare Trust Fund. The expectation is that providers who perform chiropractic manipulative treatment (CMT) will maintain proper documentation and appropriate use of modifier AT Acute treatment (chiropractic).

Metrics:

1. Average allowed services per beneficiary

2. Percentage of CMT of the spine billed with CPT® code 98942

3. Percentage of claims billed with modifier AT

Podiatry: Nail Debridement and Evaluation and Management (E/M) Services

Vulnerability:

Podiatry carries an improper payment rate of 10.8 percent for podiatry providers, which represents $162,308,133 in possible improper payments for Medicare Part B claims. A 90 percent improper payment rate is attributed to insufficient documentation and a 5.3 percent improper payment rate is attributed to incorrect coding.

After review of and research into the improper payment rate, this CBR was created to analyze the possible threat associated with podiatry services to the Medicare Trust Fund. The expectation is for providers who perform nail debridement and E/M services on the same date of service to maintain proper documentation and appropriate CPT® code assignment and use of modifier 25 Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.

Metrics:

1. Percentage of nail debridement services billed with E/M services and modifier 25

2. Percentage of nail debridement services billed with CPT® code 11721

3. Average nail debridement services, per beneficiary, per calendar year

4. Average minutes, per visit, of E/M services appended with modifier 25 and billed with nail debridement services

Lipid Panel Testing

Vulnerability:

Clinical laboratories hold an improper payment rate of 23.7 percent, which represents $907,854,203 in possible improper payments for Medicare Part B claims. A 90 percent improper payment rate is attributed to insufficient documentation and an 8 percent improper payment rate is attributed to medical necessity errors.

After review of and research into the improper payment rate, this CBR was created to analyze the possible threat to the Medicare Trust Fund associated with lipid panel testing. The expectation is for providers who refer patients for a lipid panel to order testing according to patients’ medical necessity and maintain proper documentation for patient care.

Metrics:

1. Percent of lipid panels with direct low-density lipoprotein (LDL) cholesterol test on the same day

2. Percent of beneficiaries receiving greater than one lipid panel in a rolling year

3. Percent of beneficiaries receiving greater than three LDL cholesterol tests in a rolling year

4. Percent of beneficiaries receiving greater than three total cholesterol tests in a rolling year

Ambulance Ground Transport

Vulnerability:

Ambulance services carry an improper payment rate of 7.9 percent, which represents $405,165,149 in possible improper payments for Medicare Part B claims. A 56.6 percent improper payment rate is attributed to insufficient documentation and a 31.3 percent improper payment rate is attributed to medical necessity errors. Additionally, HCPCS Level II code A0428 Ambulance service, basic life support, non-emergency transport, (BLS) holds an improper payment rate of 19.3 percent, which represents a potential $153,096,405 in improper payments.

After review of and research into the improper payment rate, this CBR was created to analyze the possible threat to the Medicare Trust Fund associated with ambulance ground transportation. The expectation is for the clinical documentation for ambulance ground transportation to validate the patient’s need for the service.

Metrics:

1. Percent of ambulance services that are basic life support (BLS), non-emergency transportation services

2. Average number of rides, per beneficiary, for BLS non-emergency

3. Average ground mileage reported with A0425, according to urban, rural, and super-rural locales

Allergy and Immunology

Vulnerability:

Allergy and immunology services hold an improper payment rate of 1.9 percent, which represents $13,391,179 in possible improper payments for Medicare Part B claims. A 63.5 percent improper payment rate is attributed to insufficient documentation and a 36.5 percent improper payment rate is attributed to incorrect coding.

After review of and research into the improper payment rate, this CBR was created to analyze the possible threat to the Medicare Trust Fund associated with allergy and immunology services. The expectation is for providers who provide allergy and immunology services to maintain proper documentation for patient care and confirm correct coding processes.

Metrics:

1. Percent of all claim lines that were allergen injections

2. Percent of allergy services that were antigen preparation

3. Percent of allergen injections submitted with an E/M service

Cataract Surgery

Vulnerability:

Eye procedures-cataract removal and lens insertion carries an improper payment rate of 12.7 percent, which represents $218,340,490 in possible improper payments made under Medicare Part B. Findings include an 87.2 percent improper payment rate attributed to insufficient documentation and a 12.8 percent improper payment rate attributed to incorrect coding.

After review of and research into the improper payment rate, this CBR was created to analyze the possible threat to the Medicare Trust Fund associated with cataract surgery services. The expectation is for providers who provide cataract surgery services to maintain proper documentation for patient care and confirm correct coding processes.

Metrics:

1. Percent of cataract surgeries billed as a complex procedure

2. Percent of beneficiaries with a cataract surgery who have a subsequent secondary cataract surgery on the same eye performed by the same or different provider within 547 days

3. Percent of cataract surgeries where postoperative care was rendered by a different provider

Get CBR Support

To ensure that all CBR information is received in a timely fashion, confirm your PECOS information and check the email box within PECOS regularly for CBR notifications.

Stay on top of CBR releases by:

1. Going to the CBR home page at cbr.cbrpepper.org/home for information about past and upcoming CBR releases; and

2. Clicking the link on the home page to join the email list to receive up-to-date information about all things CBR.

If you have questions or concerns, submit a ticket to the help desk at cbr.cbrpepper.org/Help-Contact-Us. The CBR team is there to support you; don’t be afraid to reach out!

Add CBRs to Your Compliance Arsenal

Compliance is constantly evolving and expanding to every area of patient care administration. More than ever, correct billing and coding play a key role in claim submission and in the protection of the Medicare Trust Fund. CBRs support compliance and education by raising awareness and offering tailored knowledge for recipients. All providers and support staff can take advantage of the wealth of education, analyses, and resources that accompany each CBR topic to ensure compliance in their organizations.

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Resources:

U.S. Dept. of Health and Human Services, 2021 Medicare Fee-for-Service Supplemental Improper Payment Data, Dec. 7, 2021; www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0

https://cbrfile.cbrpepper.org

https://cbr.cbrpepper.org