Comparative Billing Reports

CBR201701 Statistical Debriefing

CBR201701

The following is a description of the tables used in CBR201701, Knee Orthoses. There are links that will open the excel files that contain state and national statistics used in the analysis of suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for the items covered in CBR201701. All of the analyses in this Comparative Billing Report (CBR) include only the Healthcare Common Procedure Coding System (HCPCS) codes K0901, K0902, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1836, L1843, L1845 and L1850. CBR201701 includes claims with dates of service July 1, 2015 to June 30, 2016. These analyses are based on the latest version of claims available from the Integrated Data Repository as of November 8, 2016. Examples of each table can be found in the CBR201701 sample.

 

HCPCS Codes, and Abbreviated Descriptions

Table 1 lists each of the HCPCS codes for prefabricated off the shelf and prefabricated custom fitted knee orthoses covered in this CBR, along with an abbreviated description of each code.

 

Summary of Your Utilization

Table 2 provides a summary of the individual supplier’s utilization of the HCPCS codes included in this CBR. The total allowed charges, allowed services, and distinct beneficiary count are included for each HCPCS code. Please note that the totals may not be equal to the sum of the rows due to rounding. The number of beneficiaries is an unduplicated count for each row and the total. Since a beneficiary may have received multiple items in the list, he/she would be counted in the beneficiary count in each applicable row; however, this beneficiary would be counted only once in the total row.

 

Percentage of Beneficiaries Receiving Knee Orthoses for Both Knees

Table 3 provides a statistical analysis 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. Although receiving a brace for both knees may be justifiable, the percentage of beneficiaries needing braces for both knees should be comparable across all suppliers. Beneficiaries with allowed claims for at least two services with modifiers RT and LT from the same supplier were selected. The percentage of beneficiaries receiving knee orthoses for both knees was calculated by taking the number of beneficiaries receiving knee orthoses for both knees divided by the total number of beneficiaries and then multiplied by 100. Each supplier’s percentage is compared to his/her state and the nation using chi-square test at the alpha value of 0.05.

To view the percentage of beneficiaries receiving knee orthoses for both knees for each state and the nation, please select the following link: CBR201701 Percentage of Beneficiaries Receiving Knee Orthoses for Both Knees.xls

 

Percentage of Knee Orthoses Received Without a Visit to the Referring Physician

Table 4 provides a statistical analysis of the percentage of knee orthoses received without a recent visit to the referring physician. Since Medicare requires a prescription stating medical necessity for all items billed, this metric was designed to focus on suppliers who provided knee braces to beneficiaries who do not have a Medicare Part B claim from the physician listed on the DMEPOS claim as referring physician within 30 days of receiving the orthosis. The percentage of knee orthoses received without a visit to the referring physician in the 30 days prior to receiving the knee orthosis was calculated by taking the number of services without a visit to the referring physician divided by the total number of services and then multiplying by 100. Each supplier’s percentage is compared to his/her state and the nation using the chi-square test at the alpha value of 0.05.

To view the percentage of knee orthoses received without a recent visit to the referring physician for each state and the nation, please select the following link: CBR201701 Percentage of Knee Orthoses Received without a Visit to the Referring Physician.xls

 

Average Allowed Charges per Beneficiary

Table 5 provides a statistical analysis 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. The average allowed charges per beneficiary was calculated by taking the total allowed charges divided by the total number of beneficiaries. Each supplier’s average is compared to his/her state and the nation using t-test at the alpha value of 0.05.

To view the average allowed charges per beneficiary for each state and the nation, please select the following link: CBR201701 Average Allowed Charges per Beneficiary.xls