What is the purpose of a comparative billing report on knee orthoses?
CBR201701 was created to inform suppliers about their billing and payment patterns on claims submitted for knee orthoses. The CBR team reviewed Fee-for-Service (FFS) Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims with dates of service from July 1, 2015 to June 30, 2016. For more general information about CBRs, please visit our website at the link titled, Comparative Billing Reports.
What Healthcare Common Procedure Coding System (HCPCS) codes did you analyze for this CBR?
This CBR examines claims billed for prefabricated off the shelf knee orthoses and prefabricated custom fitted knee orthoses. The table below lists the Healthcare Common Procedure Coding System (HCPCS) codes and descriptions for the knee orthoses covered in this CBR:
|Prefabricated Off the Shelf Knee Orthoses||Prefabricated Custom Fitted Knee Orthoses|
Why was knee orthoses chosen to be a topic?
Knee orthoses was selected as a CBR topic because the Office of Inspector General (OIG) determined that Medicare improper payment rates are high for orthotic braces. The OIG Work Plan Fiscal Year 2016 report found that many services billed were not medically necessary and the documentation submitted did not meet Medicare criteria. To view details of this study, see the following web link: OIG Work Plan Fiscal Year 2016.
What is the specific focus of CBR201701 and how many suppliers received CBRs?
CBR201701 was disseminated to 1,300 suppliers, and focuses on those who submitted claims for knee orthoses whose billing and payment patterns were different from their peers. The metrics reviewed in the report include:
- Percentage of beneficiaries receiving knee orthoses for both knees
- Percentage of knee orthoses received without a visit to the referring physician (within 30 days)
- Average allowed charges per beneficiary
To review an example, see the mock supplier’s CBR at the following link: CBR201701 Sample CBR.
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 suppliers 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 suppliers about their billing and payment patterns. It may be beneficial, however, for suppliers 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.
Where can suppliers find additional information about CBR201701?
The links for the references and resources used in this CBR are located at CBR201701 Recommended Links.
How does Medicare define braces?
According the Medicare Benefit Policy Manual, braces are “rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.” More information about coverage of braces is found at the web link titled Medicare Benefit Policy Manual, Chapter 15, Section 130.
What medical conditions qualify patients for knee orthoses?
Conditions that may qualify patients for knee orthoses include knee flexion contracture, knee extension contracture, weakness or deformity of the knee and recent injury and/or surgery. Please remember that Medicare will only cover services provided to patients that are reasonable and medically necessary and that meet the criteria for coverage of knee orthoses. For more details, please see the following web link: LCD L33318.
Where can I find the coverage determination for knee orthoses for my state?
Please refer to LCD L33318 and LCA A52465 for guidelines on knee orthoses for all states. CGS Administrators covers jurisdictions J-B and J-C, and Noridian Healthcare Solutions covers jurisdictions J-A and J-D. For answers to specific questions about knee orthoses, please contact the MAC for your jurisdiction. To review coverage and payment rules, refer to the following documents: LCD L33318, LCA A52465.
When is a prefabricated orthotic considered to be custom fitted?
Custom fitted orthotics must meet two requirements. “Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment. This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary.” More information can be found at the link titled, Correct Coding – Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correction.
When is a provider considered to have specialized training?
A provider that is considered to have specialized training must meet the Federal and State licensure and regulatory requirements. They can be an orthotist “who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotics/Prosthetist Certification.” They can also be an individual specially trained to custom fit beneficiaries that have a medical need for an orthotic. Some examples of individuals who may be specially trained are an occupational or physical therapist, physician, physician assistant, clinical nurse specialist or a nurse practitioner. For more information, refer to LCA A52465.
What is minimal self adjustment?
According to the Electronic Code of Federal Regulations (e-CFR), Title 42, 414.402, “Minimal self-adjustment means an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and does not require the services of a certified orthotist (that is, an individual certified by either the American Board for Certification in Orthotics and Prosthetics, Inc., or the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training.” Details are available at the link, e-CFR, Title 42, Chapter IV, 414.402.
How often can an orthosis be replaced?
Medicare requires a new prescription if an orthosis is being replaced. According to LCA A52465, “Replacement during the reasonable useful lifetime is covered if the item is lost or irreparably damaged.” If the item is being replaced for other reasons, it may be denied. To view the chart for the reasonable useful lifetime of prefabricated knee orthoses, select the following web link: LCA A52465.
Are repairs to orthoses covered?
According to LCA A52465, repairs to an orthosis are covered if they are “necessary to make the orthosis functional. The reason for the repair must be documented in the supplier’s record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.” Documentation must support the reason for repair or replacement. For guidelines on repair of orthoses, select the following web links: LCD L33318, LCA A52465.
How was the data obtained for this report?
This report is an analysis of Medicare DMEPOS claims with allowed services for the HCPCS codes listed in Table 1 with dates of service from July 1, 2015 to June 30, 2016, and include only claim lines with a diagnosis of osteoarthritis of the knee. This analysis was based on the latest version of claims available from the Integrated Data Repository (IDR), as of November 8, 2016. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).
How were suppliers selected to receive CBRs?
The CBR data team analyzed Medicare DMEPOS claims with allowed services for the indicated HCPCS codes and identified suppliers with different billing patterns than their peers. Approximately 1,300 suppliers were selected to receive reports. Suppliers who did not receive a CBR and would like to view a mock report can see one at the following link: CBR201701 Sample CBR.
How are the peers defined?
Each billing supplier was identified by their National Provider Identifier (NPI). The peer groups that are used for comparison with individual suppliers were identified as follows:
- State: All Medicare DMEPOS suppliers with allowed charges for Knee Orthoses who are located in the individual supplier's state, as identified through the National Plan and Provider Enumeration System (NPPES) File.
- National: All Medicare DMEPOS suppliers in the nation who had allowed charges for claims for Knee Orthoses.
What do the comparison outcomes mean?
The four possible outcomes for the comparisons between the supplier and peer groups are:
- Significantly Higher - supplier’s value is higher than the peer value and the statistical test used confirms significance
- Higher – supplier’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 - supplier’s value is not higher than the peer value
- N/A (Not Applicable) - supplier does not have sufficient data for comparison
What is the meaning of Table 1?
Table 1 lists the HCPCS Codes and Abbreviated Descriptions used in this report. The 13 HCPCS Codes were identified from the Level II HCPCS codes maintained and distributed by CMS as prefabricated knee orthoses. To review an example of a mock supplier’s report, follow the web link at CBR201701 Sample CBR.
What does Table 2 show?
Table 2 is a Summary of Your Utilization and shows the mock supplier’s use of the HCPCS codes covered in this CBR. This table lists the HCPCS Codes, Allowed Charges, Allowed Services, and Beneficiary Count. To see a sample report, select the web link titled, CBR201701 Sample CBR.
What’s the significance of Table 3?
Table 3 is an example of the Percentage of Beneficiaries Receiving Knee Orthoses for Both Knees. The OIG found high improper payment rates due to insufficient documentation for beneficiaries receiving multiple knee orthoses. This metric was designed to focus on suppliers who provided knee braces to beneficiaries for both knees at a rate that exceeds his/her peers. To illustrate this, refer to Table 3 of the mock supplier’s CBR at the following link: CBR201701 Sample CBR. In this example, 63 percent of this supplier’s beneficiaries received knee orthoses for both knees. The state’s percentage is 27 percent, and the national percentage is 24 percent. This supplier’s percentage is Significantly Higher than the state and national peer groups according to the results of the chi-square statistical test used in the analysis of this data.
How should suppliers interpret Table 4?
Table 4 is an analysis of the Percentage of Knee Orthoses Received Without a Visit to the Referring Physician. For an illustration, refer to the mock supplier’s CBR on our website link at CBR201701 Sample CBR. In this example, 94 percent of this supplier’s services did not have a referral, which means that for 94 percent of the knee orthoses services, we did not find a corresponding Part B claim for the beneficiary and referring physician within 30 days of receiving the knee brace. The state’s percentage is 28 percent, and the national percentage is 38 percent. This supplier’s percentage is Significantly Higher than the percentages of the state and the nation, according to the results of the chi-square statistical test used in the analysis of this data.
What does the analysis mean in Table 5?
Table 5 is an example of the Average Allowed Charges per Beneficiary. The average allowed charges per beneficiary was calculated for each DMEPOS supplier of prefabricated knee orthoses to potentially identify wasteful spending and overutilization of these items. For an illustration, refer to the mock supplier’s CBR on our website link at CBR201701 Sample CBR. This supplier has an average allowed charge per beneficiary of $1,282.52. The state’s average is $489.07, and the national average is $581.22. This supplier’s average allowed charges per beneficiary is Significantly Higher than the averages of the state and the nation.