Comparative Billing Reports–Update

The following is contributed By Dr. Ron Short, DC, MCS-P.

In an earlier update about Comparative Billing Reports I stated that everyone was getting one.  I was wrong.  Please understand that what I published was after I had read a CBR and checked some of the carrier websites (the CMS website didn’t have anything on the CBR at the time).  My source directed me to the obscure corner of the web where the real information was hiding and I spent the past day going over it to make sure that I have it right this time.  Here are the facts:

• The Comparative Billing Reports (CBR) are being prepared by Zone Program Integrity Contractor Safeguard Services LLC.
• The CBR is then passed to Livanta LLC to be sent to the selected providers.
• The reports have been sent to the top 5,000 chiropractors, about 8% of the total chiropractors in the country.
• The data considered for these reports came from dates of service between January 1, 2009 and December 31, 2009.
• Not everyone will have a report generated for them.  To determine if a report has been generated for you go to https://cbrcontactupdate.com/ and register.  If a report has been generated you can request that it be sent to you.
• At this time CMS is not utilizing these reports to determine who is to be reviewed and/or audited.

The following are the Frequently Asked Questions regarding the chiropractic Competitive Billing Reports taken from the Safeguard Services LLC website:
 
 Q: Why am I getting this report?

A: CBR was created for the top 5,000 Chiropractors who billed services in 2009.

Q: Why was this topic chosen?

A: Chiropractic services have been identified as a vulnerability in the Medicare program. CMS recommended a comparative study be done.

Q: How are my peers defined?

A: A single chiropractor will be identified by NPI. The peer groups for comparison with the individual chiropractors are:

• State: All chiropractors who practice in the individual provider's state. If a provider practices in more than one state, he/she is compared to the chiropractors in the state where he/she has the majority of his/her business.

• Nation: All chiropractors in the nation

Q: Is there a limit to the number of chiropractic services that I can get paid for?

A: No, Medicare does not have a cap/limit for covered chiropractic care. There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.

Section 1862(a)(1)(A) of the Social Security Act (SSA) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Q: Is maintenance care a covered service under Medicare?

A: As stated in part in the MLN Matters Number SE0749, Spinal manipulation is a covered service under Medicare, no matter which phase of care you may be in; however, maintenance care is not medically reasonable and necessary and therefore not reimbursable by Medicare. Acute, chronic, and maintenance adjustments are all "covered" services, but only acute and chronic services are considered active care and may, therefore, be reimbursable. Maintenance therapy is defined (per chapter 15, Section 30.5.B of the Medicare Benefits Policy Manual) as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

Q: How was the data obtained for this report?

A: The data is from the National Claims History (NCH) at CMS (Center for Medicare and Medicaid Services). The analysis for the Chiropractic Services CBR encompasses all Medicare Part B chiropractic provider final claims data with claims from dates of service from January 1, 2009 through December 31, 2009 that are processed by July 2010 and meet the criteria listed below:

• Provider specialty equal to 35-Chiropractic
• Office is the place of service
• CPT Codes:
  • 98940 (chiropractic manipulative treatment; spinal, 1-2 regions)
  • 98941 (chiropractic manipulative treatment; spinal, 3-4 regions)
  • 98942 (chiropractic manipulative treatment; spinal, 5 regions)
• Paid and denied claims

Q: What does the word "distinct" mean in the context of the Chiropractic Services CBR?

A: The word "distinct" is used here as a statistical description meaning single or unique. A distinct beneficiary is a specific or individual beneficiary. A distinct diagnosis is a single or unique diagnosis.

Q: When calculating the average number of services billed per beneficiary (figure 1 and table 1), if a claim was billed multiple times for the same date of service (DOS) will the claim be counted more than once?

A: No, if a specific date of service was billed on multiple claims, it will only count once. Only the final claims were counted.

Q: What is the difference between Figure 1 and Table 1?

A: Figure 1 is a graphic representation of the same data represented in Table 1. In addition, Table 1 shows the statistical significance of the provider's data in comparison to their state and the nation. This holds true for Figure 2 and Table 2 as well.

Q: Why were diagnoses codes 739.0-739.9 excluded from the analysis?

A: Because the subluxation level is a required field, we chose to focus study comparisons on the neuromusculoskeletal conditions and/or symptoms necessitating treatment. These diagnoses are listed in the secondary diagnoses field(s).

Q: In Figure 2 and Table 2, how were the groups of "number of distinct diagnosis" determined?

A: These groupings of 1-2, 3, and 4+ were data driven. In other words, 50% of the claims per beneficiary fell into the 1-2 distinct diagnosis group, 25% fell into the 3 distinct diagnosis group, and 25% fell into the 4+ distinct diagnosis group.

Q: Can you further explain Figure 2?

A: Figure 2 describes the number of beneficiaries, categorized by the number of distinct diagnoses (1-2, 3, and 4 or more) used throughout 2009, associated with you, your state, and national peers. In other words, it describes the number of distinctly different diagnoses that you billed for each beneficiary over the course of the year. This does not reflect the number of diagnoses used on an individual claim. The educational value of examining billing in this way is to shed light on whether providers are using pertinent and appropriate diagnoses that are associated with the patient's neuromuscular symptom/complaint experienced on that date of service. In addition, in a self-audit, you may determine that some diagnoses are pertinent to bill on the claim, whereas, other conditions may just need to be documented in your records. There is no right or wrong determination in Figure 2, it simply represents an opportunity for education.

Q: Why are the rankings duplicated in Table 3?

A: Table 3 shows the top five diagnoses billed by you and your state and national peers in 2009. The distinct count of beneficiaries associated with each diagnosis is used to rank the diagnoses. In the top five diagnoses, some of the diagnoses had the same count of beneficiaries therefore the diagnosis tied for the ranking. Starting from the diagnosis ranked at one, every diagnosis with a tied rank will have the same rank number and the next diagnosis following the tie will have rank equal to the previous tie rank number plus the number of diagnoses tied at that rank number. You may also notice that a ranking numeral may have been skipped. We chose to count the duplicated ranking as the following number due to space considerations. Please see example below:

Analysis
 
The most important piece of information that you can get from this report is; if you received a Comparative Billing Report, Medicare considers you to be one of the top 8% of chiropractors utilizing Medicare and as such, you could be overutilizing or even fraudulent.
In their overview of the Comparative Billing Report Safeguard Services states: “The CBR is not intended to be punitive or sent as an indication of fraud. Rather it is intended to be a proactive statement that will help the provider identify potential errors in their billing practice. A CBR contains peer comparisons which can be used to provide helpful insights into their coding and billing practices. The information provided is designed to help the provider prevent improper billing and payment.”

CMS considers this to be an educational opportunity.  If you received a CBR take advantage of it and review your Medicare policies and procedures.  You need to be accurate with your Medicare documentation.  Don’t keep doing what you have always done and assume that you are doing it right.  It is uncertain how Medicare will utilize these reports in the future.
 
Action Steps
 
Review your Medicare policies and procedures.  If you received a Comparative Billing Report you would be well advised to seek outside help in the form of a records review or a full compliance audit.  At the very least, buy my book and compare your policies and procedures to those listed.  Act now to avoid potential trouble later.
 
If you have received a Comparative Billing Report Dr. Short will give you a free 15-minute phone consultation to discuss your options.  E-mail him to schedule a time: drron1085@gmail.com