The Centers for Medicare and Medicaid Services (CMS) began releasing Comparative Billing Reports (CBR) in August 2021 to some providers who have utilized telehealth during the COVID-19 public health emergency (PHE).
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. It’s aim is to support “self-audit and internal compliance,” with the presumption that outliers may be at risk of improper billing. CBR 202108: Impact of the Public Health Emergency (PHE) on Telehealth will analyze and review statistics for rendering providers who submitted Medicare Part B claims for CPT codes 99201 – 99205, 99212 – 99215 with the addition of Modifier 95 and a Place of Service (POS) 11, for dates of service between Jan. 1, 2020, and Dec. 31, 2020.
Criteria for Evaluation
The CBR takes into account the special guidance provided by CMS originally printed in the March 31, 2020, release of the Special Edition MLN Connects and updated in the April 3, 2020, release of the Special Edition MLN Connects about billing for professional telehealth services beginning with dates of services on or after March 1, 2020, and for the duration of the COVID-19 PHE:
- Use Place of Service (POS) equal to what it would have been had the service been furnished in-person.
- Use Modifier 95, indicating that the service rendered was actually performed via telehealth.
Providers will receive this CBR if they are in the top 5 percent of providers by claims volume within the top 25 specialties for the submission of CPT codes 99201 – 99205, 99212 – 99215 with a Modifier 95 and POS 11 for dates of service between Jan. 1, 2020, and Dec. 31, 2020.
Those specialties include:
- 01 (General Practice)
- 03 (Allergy/Immunology)
- 05 (Anesthesiology)
- 06 (Cardiology)
- 07 (Dermatology)
- 08 (Family Practice)
- 09 (Interventional Pain Management)
- 10 (Gastroenterology)
- 11 (Internal Medicine)
- 13 (Neurology)
- 20 (Orthopedic Surgery)
- 21 (Cardiac Electrophysiology)
- 25 (Physical Medicine and Rehabilitation)
- 26 (Psychiatry)
- 29 (Pulmonary Disease)
- 34 (Urology)
- 39 (Nephrology)
- 46 (Endocrinology)
- 50 (Nurse Practitioner)
- 66 (Rheumatology)
- 72 (Pain Management)
- 83 (Hematology/Oncology)
- 90 (Medical Oncology)
- 97 (Physician Assistant)
- C3 (Interventional Cardiology)
The CBR will highlight each provider’s total telehealth claims as compared to their clinical specialty peer group values and the national values.
Since June 2020, the HHS Office of Inspector General has flagged telehealth multiple times for its work plan, looking at “the extent to which telehealth services are being used by Medicare beneficiaries, how the use of these services compares to the use of the same services delivered in-person, and the different types of providers and beneficiaries using telehealth services.” The OIG also has conducted audits to see if these services meet Medicare requirements.
Among the various work plan items on the OIG agenda are the following:
- Data Snapshot: Review of Beneficiaries Relationships With Providers for Telehealth Services
- Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care
- Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency
- Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency
- Home Health Agencies’ Challenges and Strategies in Responding to the COVID-19 Pandemic
- Medicare Telehealth Services During the COVID-19 Pandemic: Program Integrity Risks
- Use of Medicare Telehealth Services During the COVID-19 Pandemic
- Medicaid—Telehealth Expansion During COVID-19 Emergency
As with most recent CBRs that evaluate claims within the COVID-19 PHE timeframe, CMS acknowledges that the PHE may have significantly impacted providers’ claims and claims data. However, the whole point of this CBR is to evaluate that impact, so billing practices will likely be outside a provider’s “usual.”
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 and meet Medicare billing guidelines.
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.
To learn more about the upcoming critical care services CBR, review the following:
- RELI Group’s Sample CBR: Mock Provider Data
- Recording and Transcript of Webinar reviewing the CBR 202108
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