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CMS Releases Follow-Up Comparative Billing Reports for Podiatry Services

On September 12, 2012, the Centers for Medicare and Medicaid Services (CMS) released a national provider Comparative Billing Report (CBR) targeting podiatry services. The CBRs will be released to a maximum of 5,000 podiatry service providers. This is the second time in which podiatry services have been the focal point of a CBR.

The CBRs are produced by Safeguard Services under contract with CMS and will provide comparative data to help show how these individual providers compare to other providers within the same field. These comparative studies are designed to assist providers in reviewing their coding and billing practices and utilization patterns, and take proactive compliance measures by conducting self-audits through meaningful comparisons to other podiatry providers billing similar codes. 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. CMS suggests that providers should view CBRs as an educational tool, rather than a warning, to help aid them in properly complying with Medicare billing rules. However, based upon our experience, it is clearly an indication that individuals receiving CBRs are prospective audit targets because their utilization of these codes exceeds their peers.

The recently released podiatry services CBRs are to serve as a follow up to the CBRs previously received by providers in April 2011. This repeat study is intended to serve the same educational and compliance goals as the prior study; however the newly issued CBRs provide more recent billing data–billed Medicare Part B claims data with service dates from May 1, 2011 through April 30, 2012 that were processed by July 27, 2012. Furthermore, the POS and CPT codes addressed in the recently released CBRs are identical to the codes utilized in the prior study; which include POS codes 11 (office) and 31 (skilled nursing facility), and the following CPT codes:

  • 11720–Debridement of nail(s), one to five
  • 11721–Debridement of nails, six or more
  • 99212–Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; and straightforward medical decision making
  • 99213–Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity
  • 99214–Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed problem focused examination; and medical decision making of moderate complexity
  • 99215–Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity
  • 99307–Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; and straightforward medical decision making
  • 99308–Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; and medical decision making of low complexity
  • 99309–Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed problem focused examination; and medical decision making of moderate complexity
  • 99310–Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a comprehensive interval history; a comprehensive examination; and medical decision making of high complexity

The initial podiatry service CBRs were produced due to on-going compliance issues with Medicare reimbursement regulations. A report released by the Office of Inspector General (OIG) in June 2002 found that while Medicare reimbursed podiatrists for several hundred different services, nail debridement accounted for an overwhelming percentage of the total reimbursement amount for podiatry services in Calendar Year 2000 ($233 million of $1 billion, nearly 25 percent). Furthermore, of the $233 million debridement payments, the OIG estimated that nearly 25 percent ($51.2 million) were inappropriately paid by Medicare. In addition, the study estimated that nearly 60 percent of the inappropriate nail debridement payments contained claims for related podiatry services. In light of this figure, the OIG went on to emphasize that it is inappropriate for podiatrists to seek payment for these related services when it has been determined that payment for the nail debridement itself was inappropriate.

As CMS has iterated, CBRs are intended to be an effective way to identify potential audit weaknesses and take corrective action to comply with Medicare billing rules. Red flags should rise for providers whose statistical comparisons significantly exceed their state and nationwide peers. It is important to have a qualified professional review the data, respond to CMS, and determine whether any corrective actions or compliance activities may reduce your audit risks. We feel it is imperative that providers have their CBRs analyzed, as well as submit a response to CMS challenging any statistical anomalies and addressing, where appropriate, the justifications for the services provided. At Wachler & Associates, we have assisted numerous providers with CBR analyses and the implementation of effective compliance measures for providers who have received CBRs.

If you are a recipient of a CBR for podiatry services, or are among the other provider types that have been identified to receive CBRs, please contact an experienced health care attorney at Wachler & Associates at 248-544-0888 to discuss evaluating the CBR analysis and developing appropriate compliance measures that will reduce audit risks.