Pulmonology Coding Alert

1. A provider’s value in either of the two metrics is significantly higher than their peer group or the national averages/percentages;
2. A provider has at least five total Medicare beneficiaries with claims submitted for the HCPCS Level II codes listed in the CBR; or
3. A provider has at least $150 in total allowed charges.

Each CBR’s criteria is different, but the idea behind them is that healthcare providers will use them to look at their own billing patterns. “The expectation is that providers that provide these services will maintain proper documentation for patient care and confirm correct coding processes,” the CBR team wrote.

During the CBR presentation, which was compiled by RELI Group Inc., the team examined the payment rates of bronchodilator nebulizer medications for Medicare Part B beneficiaries from July 1, 2021 to June 30, 2022. The team analyzed the payments’ accuracy and how the information complies with the protection of the Medicare Trust Fund.

The CBR team reiterated multiple times throughout the presentation that receiving a CBR is not an indication of an upcoming audit — the CBR is simply an educational tool for providers or practices to use to evaluate their own billing patterns.