MEMORANDUM
Date: June 9, 2011
To: AASM Membership
From: Patrick Strollo, MD, AASM President
Prepared by: Judy Coy and Carolyn Winter-Rosenberg
Subject: Receipt of Medicare Comparative Billing Reports
Background Information
Centers for Medicare and Medicaid Services (CMS) provided Comparative Billing Reports (CBRs) nationally to the highest frequency billers of the sleep medicine services to educate providers regarding proper billing practices. The CBRs are a communication between CMS and providers. While the AASM was made aware that the reports would be distributed, the AASM was not informed of the content of individual providers’ reports.
The cover letter sent with the CBR indicated that physicians should examine their billing practices and compare their practice to their peers. The body of the report indicates “a statistically significant difference from your peers may be an indication of improper usage.” The report further states that, “this examination assists the provider by prompting inquiries with their biller that can result in compliance with CMS guidelines; support business decisions and provides quality care.”
The American Academy of Sleep Medicine (AASM) has developed the guidelines which follow to assist members in reviewing the data provided to them by Medicare. These guidelines encourage individual physicians to send a written response to Medicare if they are concerned with any of the data they received or if they have additional unanswered questions related to the CBR. The AASM will also be sending a letter to the CMS contractor detailing the Academy’s concerns with the accuracy of the data found in the reports.
Steps to Take In Response to Receiving a Medicare CBR
The information below is very specific and only relates to a Medicare Comparative Billing Report (CBR) sent during May and June 2011 to the highest frequency billers of the following CPT/HCPCS codes: 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399 and G0400.
Carefully read the entire document sent to you from Medicare. Do not discard this information. It was sent to you by Medicare in an effort to educate you and provide you with your utilization patterns. Do not contact Medicare until you have read this entire AASM document and taken the steps indicated.
Realize the CBR may become part of your permanent Medicare profile. If the report is in error, take the time to inform Medicare of the correct information related to your practice.
- To confirm the numbers in the CBR accurately reflect your practice patterns, run a report from your system on all the services (CPT/HCPCS codes) you have provided to Medicare beneficiaries for the same time period as the Medicare CBR. Compare the number of services you provided for each code to those found in the Medicare report (CBR). If there is a large discrepancy in the number of services you provided compared to what Medicare indicated you provided, add this to your notes of items to include in your correspondence with Medicare.
- Read each of the current local coverage determinations (LCDs) that apply to your practice. For example, there may be one policy related to sleep tests and another to ordering CPAP. The content of LCDs can vary from locale to locale, so be sure to review the LCD specific to you. Look specifically at the documentation requirements related to each of the codes listed in the policy as well as to the area of the policy where it is labeled as “Documentation Requirements.”
If you do not have a copy of the LCDs which apply in your state, you can find them at the following web site.
https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
There is additional step-by-step information on the AASM web site under the Coding section to help you locate the policies that relate to your specific location. https://aasm.org/clinical-resources/coding-reimbursement/medicare-policies/
- Perform a self audit of the documentation contained in a representative sample of your records to see if your documentation supports the Medicare documentation requirements for each of the sleep medicine services you provided per the LCDs for your locale. The self audit should also include reviewing the documentation in the Evaluation and Management (E/M) services you provided prior to performing the sleep study or ordering CPAP, even though the E/M codes are not listed on the CBR. The LCDs may also indicate what must be documented in the E/M services.
- The findings from the self audit you performed will determine your next steps. If the documentation in your records supports the services billed, then proceed to step 5.
If your documentation does not support the documentation requirements found in your local LCDs for the services you have billed Medicare, please review the information at the following web site which relates to repayment of Medicare overpayments. The information found at the web site below is from Highmark Medicare Services and is included as an example only. Check your Medicare contractor website for the specific process used by the Medicare Contractor for your state, if you need to refund overpayments.
https://www.highmarkmedicareservices.com/appeals/faq/additional-appeals-op.html
You may also wish to contact a health care consultant/attorney to determine your next steps if you are uncertain about your audit findings. The AASM is not able to provide you with specific information regarding your practice patterns and/or audit findings.
- Determine what information you want to convey to Medicare concerning your CBR. Remember that if you do not point out your concerns with the CBR in writing to Medicare, Medicare may assume the data they sent you is accurate and may expect you to correct the “aberrant” billing pattern(s) if they have indicated that the patterns on your CBR are “outside the norm.” Consider including the following information, if it is pertinent and specific to your practice, in your written correspondence to Medicare:
- Currently, there is no specific primary Medicare designation for sleep medicine physicians. Sleep medicine physicians include, for example, neurologists, pulmonologists, internal medicine, psychiatrists, pediatricians, cardiologists. How was my peer group determined?
- Sleep centers vary considerably in the number of beds used to perform sleep studies. Was the number of beds in my facility/facilities considered when the norms were established for my practice?
- The physical geographic location of sleep centers greatly influences the “norms” – how was my geographic location information derived? The number of Medicare beneficiaries varies greatly by each region of the country.
- Was I compared to other credentialed sleep medicine physicians? Your policies indicate that the physicians reading sleep tests must be credentialed. Comparing a credentialed physician’s practice pattern to a non- credentialed physician’s practice pattern can also influence the norms.
- How were the norms established for the out of center/home sleep testing studies? Were a sufficient number of these studies performed prior to this review period, to establish norms for these services?
Please check the website below for the frequently asked questions and answers related to your CBR from the Medicare contractor conducting this education. www.cbrservices.com
Just Announced: The AASM will offer a half-day compliance training workshop on Saturday September 10, 2011. More details to come on the AASM website.
Note: The AASM has received feedback from members about how one can contact Medicare regarding CBR content. For questions about the CBR content or to make suggestions, you should contact the CBR Producer at 530-896-7080 or www.cbrservices.com.
For mailing address changes, you should contact the CBR Disseminator at 888-313-9666 or www.cbrcontactupdate.com. Please reference your CBR number, which is found in the cover letter that was sent with your report.
Members also can continue to contact the AASM Coding and Compliance Department by sending any additional questions about the CBR to coding@aasm.org.
