Many retina specialists have been receiving Comparative Billing Reports (CBR) from the RELI Group, a contractor for the CMS. Let’s review what you need to know about them.

Q. What is a CBR?

A. A CBR is a letter you receive from the contractor comparing your billing patterns for a particular code, or set of codes, with your peers. A CBR will present the results of statistical analyses that compare an individual provider’s billing practices, for a specific billing code, with the billing practices of that provider’s peer group and national averages. Each CBR is unique to a single provider and is only available to that individual provider; they are not publicly available.

Q. What is the purpose of this analysis?

A. The analysis is intended to be an educational process. The CBR analyses are meant to identify providers with unusual utilization patterns. They can show that some providers may need additional review and education.

Q. What codes are being targeted at this time?

A. The CBRs sent out over the last couple of months are for ophthalmic services codes (92002-92014). These reports compare your billing for these codes with other ophthalmologists in your state and around the country, although they do not identify subspecialties.

In particular, the CBR analyses are revealing that retinal specialists have a very high frequency of comprehensive eye exam codes for established patients (92014). And, although modifier use is not called out, we at Corcoran Consulting Group find that the preponderance of these are associated with the use of modifier 25.

CMS’s concern — shared by Corcoran Consulting Group — is that exams are being billed too often in conjunction with intravitreal injections performed the same day. The other concern is that a comprehensive level of service is not always warranted. An example from a sample CBR, in the Table, shows the problem.¹

In this example, there were no intermediate eye codes; only comprehensive codes were billed and paid. For new patients (92004), there is a direct correlation between the number of services and the number of patients — as one would expect.

For established patients, though, there were almost twice as many services as patients. This indicates that whenever this hypothetical provider billed an eye exam code for an established patient, it was always comprehensive. Also, that many patients in the sample were seen more than once in the year.

Q. How do I respond?

A. You are not required to respond to a CBR because it is not a notice that an audit is imminent. The CBR letter specifically states, “Receiving this CBR is not an indication or precursor to an audit, and it requires no response on your part.” However, an acknowledgment that you received the letter and are following up is advisable.

Q. What should we do?

A. A few things that you should do if you receive a CBR include:

• Read the CBR thoroughly and take it seriously. This isn’t a notice that an audit is planned, but we expect that a failure to change utilization patterns could trigger an audit.
• Make sure you are submitting from the proper family of exam codes (eye codes vs evaluation and management [E/M] codes).
• Conduct an internal chart audit and do your own analysis, or enlist help to conduct an audit to ensure compliance.
• If documentation does not meet the level of the exam billed or the frequency indicates a problem, get help with documentation and coding education for yourself and your staff.

In addition, review the changes to coding for exams in 2021. A retinal exam frequently doesn’t support 92014 simply because many of the exam elements required by the CPT definition are not needed. Just checking all of the boxes does not support the code if no medical necessity for the exam elements exists.

It may also be that the changes in documentation requirements and allowed amounts for E/M codes in 2021 will make them a more attractive alternative to eye codes in some cases.

Finally, remember that not all injection visits support an exam. Also, not all exams are — or should be — comprehensive. It is much easier to code only the exam that is needed for that patient at that time than to go through the time, aggravation, and expense of a Medicare audit. RP

REFERENCE

1. RELI Group. Sample CBR letter. Accessed June 21, 2021. https://cbr.cbrpepper.org/Portals/0/Documents/CBR_202103/CBR202103-Sample-508.pdf?ver=2021-03-23-084452-663