CMS uses a tool known as Comparative Billing Reports, or CBR, to analyze a provider’s billing or prescribing patterns. After collecting each provider’s patterns in a certain Medicare Fee-for-Service area, these patterns are then compared to those of peers in the same state, in the same specialty, and across the country. Accumulating these patterns allows CMS to estimate average billing and prescribing patterns are for providers. It also helps determine which providers may be outliers. These outliers are often informed of their status in order to encourage adjustments in billing practices if necessary. Sometimes, CMS develops “Special Edition” CBRs which give more extensive resources to a particular subset and could include up to 4 letters. Though the CBR letters generally require no response from the provider, it is important to take the information into consideration to avoid complications or possible audits in the future. Under some circumstances, a provider may also choose to follow-up or refute any inaccurate information in a CBR letter.
Recently, CMS released a new CBR letter to critical care providers who were considered after the latest CBR data accumulation. This data came from all dates of service during the year 2021 and the trend was established by looking at cumulative data from 2019 to 2021. According to the letter, the criteria for receiving the latest CBR are that a provider:
- 1. Is significantly higher compared to either state or national averages in any of the three metrics (i.e., greater than or equal to the 90th percentile), and
- 2. Has at least 30 total beneficiaries with claims for either CPT® code 99291 or 99292, and
- 3. Has at least $20,000 in total allowed charges for critical care E&M CPT® codes, and
- 4. Was a recipient of CBR202110.
In the letter, each target physician received information about where they stand in terms of state and national averages on one’s use of services with modifier 25, the number of visits per beneficiary, and the allowed charges per beneficiary. For each category, the provider’s data compared to the average can be either “Significantly Higher” (Greater than or equal to the 90th Percentile), “Higher”, “Does Not Exceed”, or “Not Applicable” (not enough data for comparison). Providers can then use these statistics as a time for evaluation of billing practices and as a possible warning that one’s practice may come under further scrutiny, audit, or investigation, if the patterns do not change. Providers who have received these letters should proactively review their documentation, coding, billing, and other practices for compliance with Medicare requirements in the event that the provider is subjected to an audit.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters. If you or your healthcare entity has any questions about Comparative Billing Reports or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or email@example.com.