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Critical Care Targeted for Medicare Comparative Billing Reports

Critical Care Targeted for Medicare Comparative Billing Reports

Beginning in November, the Centers for Medicare and Medicaid Services (CMS) began releasing Comparative Billing Reports (CBR) to some providers who perform critical care evaluation and management services.

CBRs are educational tools that reflect providers’ billing and/or prescribing patterns as compared to their peers’ patterns for the same services in their state or specialty, and nationwide. CBR 202009: Critical Care Evaluation and Management Services will analyze and review statistics for rendering providers who performed critical care evaluation and management services from March 1, 2019 through February 29, 2020. Based on the evaluation criteria, some emergency physicians may receive a CBR. 

Criteria for Evaluation

The following three metrics will be reviewed for all critical care claims for the analysis year:

  • Percentage of critical care evaluation and management services submitted with a modifier 25
  • The average number of critical care evaluation and management services per beneficiary for the provider
  • The average allowed charges for critical care services, per beneficiary.

For each metric, there are four possible outcomes for critical care providers, as their performance is compared with their peers:

  • Significantly Higher — Provider’s value is greater than or equal to the 90th percentile from the state or national mean.
  • Higher — Provider’s value is greater than the state or national mean.
  • Does Not Exceed — Provider’s value is less than or equal to the state or national mean.
  • Not Applicable (N/A) — Provider does not have sufficient data for comparison.

Physicians will receive a CBR only if their performance is significantly higher compared to either state or national averages or percentages in any of the three metrics, and they have

  • at least 30 beneficiaries with claims for 99291 and 99292, and
  • at least $20,000 or more in total allowed charges.

Why Critical Care?

Critical care evaluation and management services are specifically being targeted for upcoming CBRs because of an increase in suspected improper payments. According to CMS, the 2019 Medicare Fee-for-Service Supplemental Improper Payment Data report projected the improper payment rate for Part B critical care providers at 9 percent, representing $18 million in projected improper Medicare payments. Within that error rate, 31 percent is due to insufficient documentation, and 68.5 is due to incorrect coding. 

Code 99291 alone (which may be billed by physicians other than critical care providers) carries an improper payment rate of 18.3%, which represents over $74 million in project improper payments. 

What If I Receive a CBR?

While CMS says that receiving a CBR is not “an indication or precursor to an audit,” providers may want to prepare for that possibility by ensuring all cases are properly documented. Specifically, CMS highlighted the following in a recent webinar: “Providers should be aware that the documentation for the critical care service is complete; including medical necessity, a critically ill patient, high complexity medical decision making, and the time spent in critical care so that the assigned codes can be supported. Also, the use of modifier 25 should be reviewed and confirmed. Is there a significant, separately identifiable evaluation and management service that is documented correctly, that calls for the use of the modifier 25?”

CBRs are not posted publicly. Instead, CBRs will be sent via email from CMS CBR Contractor  RELI Group with the following email address: cbrpepper.noreply@religroupinc.com. To ensure they receive the email, physicians should update their contact email address in the Provider Enrollment, Chain, and Ownership System. Once the CBRs have been sent, providers also can access them via the CBR portal.

To learn more about the upcoming critical care services CBR, review the following:

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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