Comparative Billing Reports: what do they mean?

Family physicians have recently received Medicare comparative billing reports (CBRs) from Medicare contractor eGlobalTech. These reports measure an individual physician’s use of CPT codes 99211 through 99215 (established patient office visits) and CPT modifier 25 (a significant, separately identifiable evaluation and management service by the same physician on the same day). The reports have raised some questions and concerns, which I’ll try to address.

First, CBRs are nothing new. EGlobalTech has sent out eight other CBRs this year alone in other specialties such as podiatry, neurology, and pathology.

The CBR is very clear that it is for educational purposes only, showing how the recipient compares to his or her peers at both the state and national level in terms of using 99211-99215 and modifier 25. As noted in the frequently asked questions on eGlobalTech's web site, "The goal of these reports is to offer a tool that helps providers better understand applicable Medicare billing rules and improve the level of care they provide to their Medicare patients." It is not to suggest that the physician is necessarily billing incorrectly. To the best of my knowledge, no one in Medicare is using CBRs to deny claims or force physicians to downcode.

As part of the current CBR, eGlobalTech does calculate an "average allowed minutes per visit" using the typical times for 99211-99215 (as printed in CPT) multiplied by the number of times each of those codes was billed and then dividing by the sum of all 99211-99215 billed. It is a proxy that attempts to represent with a single number the physician's place in a bell curve for 99211-99215 use. Neither Medicare nor its contractor know how much time the physician actually spent on a given visit, and there is no suggestion in the CBR that the physician could not have done the number of services billed based on this average time.

For example, a CBR may show the physician billing 99214 and modifier 25 to Medicare at a rate significantly higher than that for his or her state or the country. There may be legitimate reasons for this, including the health status of the Medicare patients that the physician typically sees. As long as the physician's documentation supports the level of evaluation/management (E/M) service billed and the reporting of modifier 25 when used, there is no need for the physician to change what he or she is doing or what is reported to Medicare.

To ensure that their documentation supports what they bill to Medicare, physicians or someone on their practice staff should review their notes for a sample of the practice's Medicare E/M claims (with and without modifier 25). Actually, they may want to do this even if their CBR shows they are billing at a significantly lower rate than other family physicians because that may indicate that they are underreporting their services and depriving themselves of appropriate payment.

Additional information on the current CBR is available on the contractor’s web site, and the contractor will be hosting a related webinar on Dec. 10. A recording of the webinar will be available on Dec. 15 for those who cannot listen to the webinar live.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians