What is the purpose of a comparative billing report on subsequent hospital care?
CBR201615 was created to inform internal medicine Medicare providers (specialty 11) about their billing and payment patterns on claims submitted for subsequent hospital care. The CBR team reviewed Fee-for-Service (FFS) Medicare claims with dates of service from January 1, 2015 to December 31, 2015. For more information about CBRs, please visit our website at the link titled, Comparative Billing Reports.
Why was subsequent hospital care chosen to be a topic for a CBR?
This topic was selected because subsequent hospital care is an area that is vulnerable to fraud, waste, and abuse. The Centers for Medicare & Medicaid Services (CMS) determined that most improper payments for subsequent hospital care were due to insufficient documentation. According to the Medicare Fee-For-Service 2014 Improper Payments Report, “The improper payment rate for subsequent hospital visits was 20.7 percent, accounting for 2.4 percent of the overall Medicare FFS improper payment rate. The projected improper payment amount during the 2014 report period was $1.2 billion.” For more detailed information, see the following web link: Medicare Fee-For-Service 2014 Improper Payments Report (Executive Summary).
What is the specific focus of CBR201615?
CBR201615 focuses on internal medicine Medicare physicians whose billing and payment patterns were different from their peers. The metrics in the report include:
- Percentage of beneficiaries discharged within one day of a CPT® code 99233 service
- Average allowed minutes per beneficiary
- Percentage of total services billed as CPT® code 99233
To review an example, see the mock provider’s CBR at the following link: CBR201615 Sample CBR.
What Current Procedural Terminology (CPT®) codes were analyzed for this CBR?
The CPT® codes, descriptions and typical times are listed below:
Patient is stable, recovering, or improving
Patient is responding inadequately to therapy or has developed a minor complication
Patient is unstable or has developed a significant complication or a significant, new problem
Is receiving a CBR an indication that I’m billing incorrectly?
No. Receiving a CBR is not necessarily indicative of incorrect billing; however, it does mean that your billing is different from your peers. There can be many reasons your billing patterns may vary, including region, subspecialty, and patient acuity. If you still have questions and/or concerns after reviewing your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.
Should providers be concerned about impending audits if they received a CBR?
The CBR team does not conduct audits nor have access to medical documentation needed to perform audits of claims. The purpose of CBRs is to inform providers about their billing and payment patterns. It may be beneficial, however, for providers to conduct self-audits. Resources that can help with setting up an audit process are located on our CBR website page at the link titled, Self-Audit Help.
Does the information in the CBR change the documentation and billing requirements established by the Medicare Administrative Contractors (MACs)?
No. The CBR is informational and does not alter, change, or negate any of the documentation and billing requirements established by the MACs. If you have questions about billing, please use the following CMS website link to access contact information for your MAC: Review Contractor Directory – Interactive Map.
Where can providers find additional information regarding Medicare guidelines for subsequent hospital care?
The links for the references and resources used in this CBR are located at CBR201615 Recommended Links.
What is a modifier?
A modifier is a two-digit value that is added to CPT® codes and Healthcare Common Procedure Coding System (HCPCS) codes. Modifiers are used to show a service is different in some way without changing the definition or meaning of the service. Modifiers add specificity and improve the accuracy of coding. Level I modifiers are two numeric digits found in the CPT® Professional Edition (also known as CPT® Manual), and are updated annually by the American Medical Association (AMA). Level II modifiers are two characters (alpha and numeric) and are updated by CMS. A partial list of Level II modifiers can be found in the CPT® Manual, and a full list is found in the HCPCS Level II Professional Edition (also known as HCPCS Manual). The manuals are available from the web link titled, AMA Store.
What is the AI modifier?
Noridian Healthcare Solutions states the following about the AI modifier: “This modifier distinguishes the Principal Physician who oversees patient’s care when performing evaluation and management (E/M) services and is only appended by that physician. It is imperative, so that other specialties may bill their claims for the same E/M code and not receive denials.” The AI modifier is an informational only modifier and does not have any effect on the processing or payment amount. More information is available on the Noridian Healthcare Solutions website at the link titled, Modifier AI - Principal Physician of Record.
When should the AI modifier be appended?
The AI modifier is used to identify the Principal Physician of Record (i.e., the admitting or attending physician), who is primarily responsible for the patient’s care in an inpatient or nursing facility. The AI modifier is appended to procedure codes for initial inpatient hospital visits and initial nursing facility visits. Payment modifiers should be appended to claims before adding the AI modifier. More information about the AI modifier can be found on the WPS Government Health Administrators website at the following web link: Modifier AI Fact Sheet.
Will my claim be denied if I use the AI modifier inappropriately?
No. Since the AI modifier is for informational purposes and has no impact on payment of claims, the incorrect use of the modifier will not cause a claim to be denied. Per the Modifier AI Fact Sheet:
“Note: Medicare will allow services when a provider uses this modifier incorrectly on an
office or other outpatient service. Medicare will allow services when someone other than
the principal physician of record uses this modifier. Medicare can allow services provided
by a physician called in to see the patient even though the principal physician of record does
not append this modifier to his/her claim or he/she has not yet submitted the claim to Medicare.”
To review additional information about use of the AI modifier, see the following web link: Modifier AI Fact Sheet.
Can two different providers in the same group practice and same specialty bill a subsequent code on the same day?
No. Regardless of how many physicians within the same specialty/group treat a patient on the same day, only one subsequent care visit will be payable for those services. An article in the publication, The Hospitalist, provides the following explanation: “Physicians in the same group practice and specialty bill and are paid as though to a single physician. In other words, if two hospitalists evaluate a patient on the same day (e.g., one hospitalist sees the patient in the morning, and another one sees the patient in the afternoon), the efforts of each medically necessary evaluation and management service may be captured…Instead of reporting each service separately under each corresponding hospitalist’s name, the hospitalists select subsequent hospital care code 99231-99233 representing the combined visits and submit one appropriate code for the collective level of service.” For clarification, see the article in The Hospitalist at the following web link: Daily Care Conundrums.
What CPT® code should be used if the service provided does not meet the requirements for an initial hospital care code?
CMS requires that the CPT® code on the claim accurately reflects the level of service provided; however, an exact match of the code descriptors of the low-level inpatient consultation codes to those of the initial hospital care codes does not exist. According to the MLN Matters® publication, MACs should “not find fault with providers who report a subsequent hospital care CPT® code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.” To find more answers to these types of questions, see the MLN Matters® publication at the web link titled, Questions and Answers on Reporting Physician Consultation Services.
Should a provider bill for subsequent hospital care or hospital discharge day management?
Hospital Discharge Day Management Services should be billed only by the attending physician of record or the physician acting on behalf of the attending physician. According to a Medicare Learning Network® publication, “Physicians and qualified NPPs who manage concurrent health care problems not primarily managed by the attending physician should use the Subsequent Hospital Care code from CPT® code range 99231 – 99233 for a final visit.” More details are found in the Medicare Learning Network® publication at the link, Provider Inquiry Assistance.
Can more than one provider bill a subsequent inpatient code on the same day?
Yes. If two physicians with different specialties treat the same patient for different reasons (i.e., different diagnoses) on the same day, then each may bill a subsequent visit. Coverage of services is based on each physician’s notes and the medical necessity of the services. According to The Hospitalist: “If each hospitalist is responsible for a different aspect of the patient’s care, payment is made for both visits if:
- The hospitalists are in different specialties and different group practices;
- The visits are billed with different diagnoses; and
- The patient is a Medicare beneficiary or a member of an insurance plan that adopts Medicare rules.”
For more information, see the following web links:
How was the data obtained for this report?
Claims with CPT® codes covered in this CBR, with dates of service from January 1, 2015 to December 31, 2015, were downloaded from the CMS Integrated Data Repository (IDR) and loaded into the Palmetto GBA Medicare Data Warehouse. Then, each provider’s data was compared to that of the peers in their own state and the nation, as identified by the National Plan and Provider Enumeration System or NPPES. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).
How were providers selected to receive CBRs?
The CBR data team analyzed claims with allowed services for CPT® codes 99231, 99232 and 99233, and identified those providers with different billing patterns than their peers. Out of those claims, approximately 7,700 providers were selected to receive reports. Providers who did not receive a CBR can view a mock report at the following link: CBR201615 Sample CBR.
How are the peers defined?
Each billing provider was identified by their National Provider Identifier (NPI), which is supplied by NPPES. The peer groups that are used for comparison with individual providers were identified as follows:
- State: All Medicare providers located in the provider's state with a specialty of internal medicine (11) with allowed charges for the CPT® codes 99231-99233,
- National: All Medicare providers in the nation with a specialty of internal medicine (11) with allowed charges for the CPT® codes 99231-99233
What do the comparison outcomes mean?
The four possible outcomes for the comparisons between the provider and peer groups are:
- Significantly Higher - provider’s value is higher than the peer value and the statistical test used confirms significance
- Higher – provider’s value is higher than the peer value, but either the statistical test does not confirm significance or there is insufficient data for comparison
- Does Not Exceed - provider’s value is not higher than the peer value
- N/A (Not Applicable) - provider does not have sufficient data for comparison
What is the meaning of Table 1?
Table 1 is a list of the CPT® Codes, Presenting Problems, and Key Components. Also, Table 1 provides explanations for the patient histories, examinations, and medical decision making for each code. To review an example of a mock provider’s report, follow the web link at CBR201615 Sample CBR.
What does Table 2 show?
Table 2 is a Summary of Your Utilization for Codes and shows a mock provider’s use of CPT® codes 99231, 99232 and 99233. This table lists the CPT® codes, allowed charges, allowed services and beneficiary count. To see a sample report, select the web link titled, CBR201615 Sample CBR.
What’s the significance of Table 3?
Table 3 is an example of the Percentage of Beneficiaries Discharged within One Day of a CPT® code 99233 Service. To illustrate this, refer to Table 3 of the mock provider’s CBR at the following link: CBR201615 Sample CBR. In this example, 15 percent of the provider’s beneficiaries were discharged within one day of CPT® code 99233, while the state’s discharge rate was seven percent and the national rate was four percent. This resulted in the provider’s percentage being Significantly Higher than the state and national peer groups for the percentage of beneficiaries discharged within one day of CPT® code 99233. To view the results for all states and the nation, select the following link: CBR201615 Statistical Debriefing.
How should providers interpret Table 4?
Table 4 is an analysis of the Average Allowed Minutes per Visit. For an illustration, refer to the mock provider’s CBR on our website link at CBR201615 Sample CBR. In this example, the provider has an average of 29.29 minutes per visit, which is Higher than the state’s average of 28.95 minutes and Significantly Higher than the national percentage of 27.54 minutes. To review the results for each state and the nation, see the following link: CBR201615 Statistical Debriefing.
What are the comparisons in Table 5?
Table 5 is an example of the Percentage of Total Services Billed as CPT® Code 99233. This table provides a comparison of the mock provider’s percentage of total services billed as CPT® code 99233 to that of the state and the nation. In this example, 44 percent of this provider’s services were billed as CPT® code 99233. The state also billed 44 percent, while the national rate was 32 percent. Therefore, the provider Does Not Exceed the state’s value, but is Significantly Higher than that of the nation.To review the results for each state and the nation, see the following link: CBR201615 Statistical Debriefing.