The Centers for Medicare and Medicaid Services (CMS) is once again releasing Comparative Billing Reports (CBRs) to some providers who perform critical care evaluation and management services. This time, they will be analyzing claims that occurred in part during the COVID-19 public health emergency (PHE), with dates of service from Jan. 1, 2020, through Dec. 31, 2020.
This is the second year in a row that critical care evaluation and management services have been targeted for CBRs. In late 2020, CMS released CBRs to providers who performed critical care evaluation and management services from March 1, 2019 through February 29, 2020.
In an online presentation about the CBR, CMS said they are conducting this second wave of critical care CBRs after an analysis of 2020 claims showed that there were 93,872 rendering providers with combined allowed charges of over $1.1 billion for providers that submitted claims for critical care services. CMS also cited the 2020 Medicare Fee-for-Service Supplemental Improper Payment Data report, which reflected a 9.7% improper payment rate for Part B critical care providers, representing $21 million in projected improper payments. Code 99291 alone (which may be billed by physicians other than critical care providers, such as emergency physicians) carries an improper payment rate of 19.7%, which represents over $196 million in project improper payments just for that code.
Criteria for Evaluation
As with the earlier critical care CBRs, the following three metrics will be reviewed for all critical care claims for 2020:
- 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 in any of the three metrics is significantly higher compared to either state or national averages, and they have
- at least 30 beneficiaries with claims for 99291 and 99292, and
- at least $20,000 or more in total allowed charges.
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?”
Since the majority of the analysis period falls within the COVID-19 PHE emergency, CMS also urged providers to “keep in mind that some of your billing and coding analysis may be affected by the PHE.”
CBRs are not posted publicly. Instead, CBRs will be sent via email from CMS CBR Contractor RELI Group with the following email address: firstname.lastname@example.org. 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.
For more information about the upcoming critical care services CBR, review the following:
- CMS’s recent announcement of the upcoming critical care evaluation and management services CBR
- RELI Group’s Sample CBR: Mock Provider Data
- Recording and Transcript of a Webinar reviewing the CBR 202105 from May 21, 2021
- The CBR homepage
- An upcoming webinar to review the new CBR 202105, scheduled for June 9, 2021, at 3 p.m. ET. Register here.
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