Comparative Billing Reports

CBR201805 Statistical Debriefing

CBR201805

The following is a description of the metrics and samples of the tables presented in CBR201805, Knee Orthoses Referring Providers, and the corresponding peer group statistics used for the comparisons. The analyses in this Comparative Billing Report (CBR) focus on the Healthcare Common Procedure Coding System (HCPCS) codes for custom-fitted and prefabricated off-the-shelf knee orthoses. CBR201805 includes Medicare Part B, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims with dates of service from January 1, 2017 to December 31, 2017. These analyses are based on the latest version of claims available from the Integrated Data Repository as of April 3, 2018. Below are examples of each table published in the CBR201805 sample for a mock provider.

 

HCPCS Codes and Abbreviated Descriptions

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

Table 1: HCPCS Codes and Abbreviated Descriptions

Custom-Fitted Knee Orthoses

Prefabricated Off-the-Shelf Knee Orthoses

HCPCS Code

Description

HCPCS Code

Description

L1810

Knee orthosis, elastic with joints

L1812

Knee orthosis, elastic with joints

L1820

Knee orthosis, elastic with condylar pads and joints

L1830

Knee orthosis, immobilizer

L1831

Knee orthosis, locking knee

L1833

Knee orthosis, adjustable knee

L1832

Knee orthosis, adjustable knee

L1836

Knee orthosis, rigid without joints

L1834

Knee orthosis, without knee joint

L1848

Knee orthosis, double upright

L1840

Knee orthosis, de-rotation

L1850

Knee orthosis, Swedish

L1843

Knee orthosis, single upright

L1851

Knee orthosis, single upright

L1844

Knee orthosis, single upright

L1852

Knee orthosis, double upright

L1845

Knee orthosis, double upright

 

 

L1846

Knee orthosis, double upright

 

 

L1847

Knee orthosis, double upright

 

 

L1860

Knee orthosis, modification

 

 

 

Table 2: Summary of Your Referrals for Knee Orthoses

Table 2 provides a summary of the individual provider’s referrals for the HCPCS codes included in the CBR. Below is an example of table 2 from the CBR sample:

Table 2: Mock Data Summary of Your Referrals for Knee Orthoses
Dates of Service: January 1, 2017 - December 31, 2017

Type

HCPCS Code

Allowed

Charges

Allowed

Services

Beneficiary

Count

Custom-Fitted

L1810

$0

0

0

Custom-Fitted

L1820

$0

0

0

Custom-Fitted

L1831

$0

0

0

Custom-Fitted

L1832

$10,028

14

12

Custom-Fitted

L1834

$0

0

0

Custom-Fitted

L1840

$0

0

0

Custom-Fitted

L1843

$0

0

0

Custom-Fitted

L1844

$0

0

0

Custom-Fitted

L1845

$0

0

0

Custom-Fitted

L1846

$0

0

0

Custom-Fitted

L1847

$0

0

0

Custom-Fitted

L1860

$0

0

0

Custom-Fitted

Subtotal

$10,028

14

12

Off-the-Shelf

L1812

$0

0

0

Off-the-Shelf

L1830

$0

0

0

Off-the-Shelf

L1833

$0

0

0

Off-the-Shelf

L1836

 

$0

0

0

Off-the-Shelf

L1850

$0

0

0

Off-the-Shelf

L1851

$0

0

0

Off-the-Shelf

L1852

$1,844

2

1

Off-the-Shelf

Subtotal

$1,844

2

1

Total

 

$11,873

16

13


For this mock provider, the table indicates that he/she has referred total allowed charges of $11,873 for the HCPCS codes included in the study. This provider has referred 16 allowed services to 13 beneficiaries.                                                                

 

Please note that the totals may not be equal to the sum of the rows due to rounding. Also, the beneficiary counts are unduplicated counts for each row, subtotal, and total. For example, a beneficiary receiving multiple services with different HCPCS codes within this time period would be counted in the beneficiary count in each applicable row; however, this beneficiary would be counted only once in the subtotal and total rows.

 

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 percentage is calculated for each individual referring provider and each peer group as follows:
 

( Number of Beneficiaries Receiving Knee Orthoses for Both Knees / Total Number of Beneficiaries ) x 100
 

The OIG found high improper payment rates due to insufficient documentation for beneficiaries receiving multiple knee orthoses. This metric was designed to focus on providers who referred 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 providers. Beneficiaries with allowed claims for at least two services with modifiers RT and LT from the same referring provider 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 provider’s percentage is compared to his/her state and the nation using the chi-square test at the alpha value of 0.05. Below is an example of table 3 and the results of this analysis for our mock provider.

Table 3: Mock Percentage of Beneficiaries Receiving Knee Orthoses for Both Knees
Dates of Service: January 1, 2017 – December 31, 2017

Number of Beneficiaries with Both

Total Number of Beneficiaries

Your Percent

Your State’s Percent

Comparison with

Your State

National

Percent

Comparison with National Percent

3

13

23%

25%

Does Not Exceed

21%

Higher

A chi-square test was used in this analysis, alpha = 0.05  
                                                        

The mock provider has referrals for three beneficiaries who received knee orthoses for both knees out of a total of 13 Beneficiaries. Dividing 3 by 13, and multiplying by 100, yields his/her percentage of 23 percent. The state’s percentage is 25 percent and the national percentage is 21 percent. The statistical test used in this analysis, the chi-square test, indicates that this provider’s percentage “Does Not Exceed” that of the state, but is “Higher” than the national peer group.
 

To view the percentage of beneficiaries receiving knee orthoses for both knees for each state and the nation, please select the following link: CBR201805 Percentage of Beneficiaries Receiving Knee Orthoses for Both Knees.xls

 

Percentage of Services Defined as Custom-Fitted

Table 4 provides a statistical analysis of the percentage of services defined as custom-fitted. The percentage is calculated for each individual referring provider and each peer group as follows:
 

( Number of Services Defined as Custom-Fitted  / Total Number of Services ) x 100
 

This metric is calculated as the number of knee orthoses defined as custom-fitted (refer to table 1 for HCPCS listing) divided by the total number of knee orthoses services that are included in the study, and then multiplied by 100. Each provider’s percentage is compared to his/her state and the nation using the chi-square test at the alpha value of 0.05. Below is an example of table 3 and the results of this analysis from a mock provider.

 

Table 4: Mock Percentage of Services Defined as Custom-Fitted
Dates of Service: January 1, 2017 – December 31, 2017

Number of Custom-Fitted

Total Number of Services

Your Percent

Your State’s Percent

Comparison with Your State

National

Percent

Comparison with National Percent

14

16

88%

45%

Significantly Higher

35%

Significantly Higher

 A chi-square test was used in this analysis, alpha = 0.05.

In this example, the mock provider has referred 14 services that are defined as custom-fitted, out of a total of 16 services. Dividing 14 by 16, and multiplying by 100, will yield his/her percentage of 88 percent. The state’s percentage is 45 percent, and the national percentage is 35 percent. The statistical test used in this analysis, the chi-square test, presents this provider’s percentage as “Significantly Higher” than both peer group percentages.

 

To view the percentages of services defined as custom-fitted for each state and the nation, please select the following link: CBR201805 Percentage of Services Defined as Custom-Fitted.xls.

 

Percentage of Services without a Visit to the Referring Provider

Table 5 provides a statistical analysis of the percentage of services without a visit to the referring provider within 90 days prior to the DMEPOS service date. The service date is defined as the date that the knee orthosis order was filled by the DMEPOS supplier.  The percentage is calculated for each individual referring provider and each peer group as follows:

 

(Number of Services Without a Visit to the Referring Provider / Total Number of Services) x 100

 

The percentage of knee orthoses received without a visit to the referring provider in the 90 days prior to receiving the knee orthosis was calculated by taking the number of services without a visit to the referring provider divided by the total number of services, and then multiplied by 100. Each provider’s percentage is compared to his/her state and the nation using the chi-square test at the alpha value of 0.05. Below is an example of table 5 and the results of this analysis from our mock provider.

 

Table 5: Mock Percentage of Services without a Visit to the Referring Provider
Dates of Service: January 1, 2017 – December 31, 2017

Number of Services without a Visit

Total Number of Services

Your Percent

Your State’s Percent

Comparison with

Your State

National

Percent

Comparison with National Percent

2

16

13%

38%

Does Not Exceed

40%

Does Not Exceed


   A chi-square test was used in this analysis, alpha = 0.05. 
 

In this example, the mock provider has referred two services without a visit to the referring provider, out of a total of 16 services. Dividing 2 by 16, and multiplying by 100, will yield his/her percentage of 13 percent. The percentage for the state is 38 percent, and the national percentage is 40 percent. The statistical test used in this analysis, the chi-square test, presents this mock provider’s percentage as “Does Not Exceed” both peer group percentages.

 

To view the percentage of knee orthoses received without a visit to the referring provider for each state and the nation, please select the following link: CBR201805 Percentage of Knee Orthoses Received without a Visit to the Referring Provider.xls

 

Average Allowed Charges per Beneficiary

 

Table 6 provides a statistical analysis of the average allowed charges per beneficiary. The average is calculated as follows:

 

( Total Allowed Charges / Total Number of Beneficiaries )

 

The average allowed charges per beneficiary was calculated for each referring provider 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 provider’s average is compared to his/her state and the nation using t-test at the alpha value of 0.05. Table 6 is an example of the results of this analysis.

                                

Table 6: Mock Average Allowed Charges per Beneficiary
Dates of Service: January 1, 2017 – December 31, 2017

Total Charges

Total Number of Beneficiaries

Your Average

Your State’s Average

Comparison with

Your State

National

Average

Comparison with National Average

$11,872.55

13

$913.27

$651.72

Significantly Higher

$627.12

Significantly Higher


   A t-test was used in this analysis, alpha = 0.05. 
 

This mock provider has referrals totaling $11,872.55 for the knee orthoses included in this CBR.  This covers 13 beneficiaries.  Dividing $11,872.55 by 13 beneficiaries yields this mock provider’s average per beneficiary of $913.27. The t-test indicates that this mock provider’s average is “Significantly Higher” than both peer group averages.

 

To view the average allowed charges per beneficiary for each state and the nation, please select the following link: CBR201805 Average Allowed Charges per Beneficiary.xls.