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CMS to Release Comparative Billing Reports for Evaluation and Management Services

CMS (Centers for Medicare & Medicaid Services) expects to publish Comparative Billing Reports (CBRs) on Evaluation and Management (E/M) Services on June 4, 2012.

Since 2010, CMS, through Safeguard Services (SGS), has produced national comparative billing reports in select fields. These comparative studies are designed to help providers review their coding and billing practices and utilization patterns, and take proactive compliance measures. A CBR outlines the provider’s billing patterns and compares those patterns to other similar entities. Pursuant to Safeguard Services website, E/M services CBRs will be given to providers that meet the following criteria:

  • Filed Medicare Part B final claims with dates of service from January 1 to December 31, 2011;
  • Claims were retrieved from the Integrated Data Repository (IDR) on April 13, 2012;
  • The provider is a specialty primary care provider (General Practice, Family Practice, Internal Medicine, Nurse Practitioner, Multispecialty Clinic or Group Practice, Preventive Medicine, or Physician Assistant);
  • Billed CPT codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215;
  • Place of service was in the office (11);
  • Allowed charges greater than $0; and
  • Provided greater than or equal to 100 total units for the combination of the aforementioned CPT codes.

The sole intent of conducting CBRs is to educate providers as to potential fraud and abuse; they are not punitive. Providers should view CBRs as a tool, rather than a warning, as a way to aid them in properly complying with Medicare billing rules. It is also important to understand that CBRs do not contain patient or case-specific data, but rather only summary billing information as a method of ensuring privacy.

E/M services are specifically targeted because they are susceptible to fraud and abuse. From 2001 to 2010 Medicare payments for E/M Services increased by 48 percent. CMS will publish CBRs that analyze Medicare Part B final claims data from January 1, 2011 through December 31, 2011. Collective trends in the individual CBRs will be published for the nation to inspect.

If you are a recipient of a CBR for E/M services, or are among the other provider types that have been identified to receive CBRs (i.e. ordering DME, physical therapists, chiropractors, ambulance, hospice, podiatry, sleep studies and cardiology), please contact an experienced healthcare attorney at Wachler & Associates at 248-544-0888 to discuss evaluating the CBR analysis and development of an appropriate compliance plan that will reduce audit risks.