Pulmonology Coding Alert

Remember that a CBR is an educational tool.

A recent comparative billing report (CBR), compiled by RELI Group Inc., examined the payment rates of bronchodilator nebulizer medications for Medicare Part B beneficiaries. From 2021 to 2022, the analysis team looked at providers’ reimbursement rates for different medication categories and how the paid claims stacked up against national and specialty averages.

Look at the metrics to compare your practice’s statistics.

Get to Know the Bronchodilator Nebulizer Medication Codes

Researchers examined the following six HCPCS Level II codes in four categories:

Contracted by the Centers for Medicare & Medicaid Services (CMS) to develop, produce, and distribute CBR reports, the RELI team analyzed the payments of bronchodilator nebulizer medications to examine the accuracy of the payments and how that information complies with CMS’s protection of the Medicare Trust Fund.

Understand What the CBR Analyzes

The CBR’s analysis includes claims with dates of service (DOS) from July 1, 2021, to June 30, 2022. “The results showed that over 151,000 providers are listed as referring providers on claims for bronchodilator nebulizer medications,

which represent over $283 million in allowed charges,” stated RELI’s Annie Barnaby during the Dec. 14, 2022, presentation.

The RELI team created the CBR to “analyze the possible threat to the Medicare Trust Fund associated with bronchodilator nebulizer medications.” The analysis followed review and research of the 2021 Medicare Fee-for-Service Supplemental Improper Payment Data report, in which the team found an improper payment rate of 13.5 percent for nebulizers and related drugs — or $111,637,609 (www.cms.gov/files/ document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0).

Several errors contributed to the improper payment rate for Medicare Part B nebulizers and related drugs, but the most significant errors include:

• Insufficient documentation (66.2 percent)
• Medical necessity errors (12.9 percent)

In December 2022’s CBR, the team analyzed two metrics that compared a provider’s billing patterns to the billing patterns of similar providers across the country and in the provider’s specialty. The results garnered four possible outcomes:

• Significantly higher: Provider’s value is greater than or equal to the 90th percentile from the national or specialty average.
• Higher: Provider’s value is greater than the national or specialty average.
• Does not exceed: Provider’s value is less than or equal to the national or specialty average.
• Not applicable: There is not enough data for comparison.

90th percentile: If a provider’s value falls under the significantly higher outcome, this means that their payment values are higher than or equal to 90 percent of the compared values in a specialty or the nation.

Examine Each Category’s Average Allowed Units

The first metric looks at the average allowed units, per beneficiary, by the categories listed above. The team calculated the metric by dividing the number of allowed units for each category by the number of unique beneficiaries who received the medications in each category.

Example: A pulmonary disease provider reported 4,646 allowed SABA units during the study’s timeframe with three unique beneficiaries. The provider’s average is calculated by dividing the allowed units by the beneficiaries, which results in an average of 1,548.67. When the provider’s average is compared to the 90th percentile national average of 1,199.33, the provider’s rate is significantly higher than the national average.

At the same time, when the same provider’s average is compared to the specialty-specific 90th percentile average of 1,102.11, the provider’s average again falls under the significantly higher outcome.

Learn the Reimbursement Rate for J7620

The second metric centers around J7620 and how the submitted claims are reimbursed compared to a provider’s total number of paid claims submitted for all bronchodilator nebulizer medications. “To calculate Metric 2, the total number of paid claims submitted for J7620 is divided by the total number of paid claims submitted for bronchodilator nebulizer medications,” Barnaby explained.

Example: A pulmonary disease provider reported one paid claim submitted for J7620 and a total of 52 paid claims submitted for all their bronchodilator nebulizer medications. After dividing the one J7620 paid claim submitted by the 52 total bronchodilator nebulizer medication paid claims and multiplying by 100, the provider’s rate for this metric is 1.92 percent. When compared to the national and specialty rates in the table below, the provider’s rate does not exceed the percent of paid claims for bronchodilator nebulizer medications submitted for J7620.

Review the CBR to See How Your Billing Compares to Your Colleagues

Providers may wonder if receiving a CBR could serve as an audit warning, but they need not fear retaliation due to the report’s numbers. “A CBR is not, in any way, an indication of or a precursor to an audit. It also is not an indication of wrongdoing. [T]he CBR is educational in nature, and should be reviewed as such,” Barnaby stated.

Resource: To read the entire comparative billing report, visit the RELI website at https://cbr.cbrpepper.org/About-CBR/CBR-202210.