Comparative Billing Reports: If Your E/M Use Is Flagged, Take These 6 Urgent Steps

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If your practice receives a comparative billing report (CBR), will your staff understand its significance and know what steps to take?

Payers track your use of codes. All insurance companies track physi­cians’ use of exams, tests, and surgical procedures. Each quarter, your payers perform an analysis to identify outliers.

Apples, oranges, and supposed outliers. Payers may flag you as an out­lier if you use a particular CPT code, a modifier, or even a diagnosis code at a greater rate than your peers. But who are your peers? Despite the existence of subspecialty-specific taxonomy codes, payers will compare you against physi­cians across your entire specialty, which can result in an apples-to-oranges comparison (not, for example, a retina-to-retina comparison).

What’s in the CBR? The CBR will indicate how far your code utilization exceeds that of your peers.

What’s next? If the payer believes that physicians in your practice may be overutilizing certain codes, it may decide to audit them. You need to take this seriously and make sure you are audit-ready.

CBRs for Eye Exams

Suppose you are flagged as an outlier for your use of level 4 and 5 exam codes for new and established patients. Your first CBR will probably come from a commercial plan. When you receive it, you and your staff should promptly take the following steps.

Step 1: Read the report thoroughly and prioritize your response. A CBR often serves as a warning that if the pat­tern of utilization continues, an audit will soon follow. 

Step 2: Make sure you are submit­ting from the proper family of exam codes. Ophthalmologists are unique in that they have two code families to choose from, E/M codes and Eye visit codes. Whichever one you opt for, make sure that your documentation supports the code that you use.  

Step 3: Conduct your own internal chart audit to assure compliance. For each level of code for which you have been flagged as an outlier, pull a small sample of records. Make sure there is an identifiable physician signature and check that your signature log is up to date. In an actual audit, the payer would use that log to verify the signatures that appear in the charts. If you are using electronic health records (EHRs), you need an EHR protocol that guarantees the physician’s signature is secure.

Step 4: Make sure your documenta­tion justifies the level of exam billed. You can base your E/M exam either on the level of medical decision-making or on physician time.

Billing based on level of medical decision-making. The Final Determina­tion Table for Medical Decision-Mak­ing features three components: the number and complexity of problems addressed; the amount and/or complex­ity of data to be reviewed and analyzed; and the risk of complications and/or morbidity or mortality of patient man­agement. Make sure the documentation for at least two of those components meets the requirements for the level of exam that you have billed.

Billing based on physician time. If you bill based on physician time on the date of the encounter, make sure that the time is well documented and allocated to any of these areas:

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing a sepa­rately obtained history
• Ordering medications, tests, or procedures
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the pa­tient, family, or caregiver
• Documenting clinical information in the EHR or other health record
• Referring/communicating with other health care professionals (HCPs) when not reported separately
• Care coordination when not report­ed separately

To support use of the level 4 and 5 E/M codes, how much time does the physician need to spend in one or more of the above activities?

For a new patient:

• 99204: 45-59 minutes
• 99205: 60-74 minutes

For an established patient:

• 99214: 30-39 minutes
• 99215: 40-54 minutes

Step 5: Make sure that the primary diagnosis relates to the chief complaint. Select ICD-10 code(s) to the highest level of specificity. Only report diagno­sis codes that pertain to the day’s exam.

Step 6: Review your findings. If your documentation supports the level of exam billed–well done! If not, take immediate corrective action.

Use the AAOE’s resources. For primers, Q&As, and other free resourc­es, visit aao.org/em. For an in-depth guide, purchase Conquering New E/M Documentation Guidelines for Oph­thalmology (aao.org/store).

Problems to Watch For

There may be problems with documen­tation in the following scenarios:

• All new patient exams are routinely coded as 99204. (To bill a new patient for this level of exam, your documen­tation should demonstrate either 45-59 minutes of physician activity or a level of medical decision-making of moder­ate complexity.)
• Your biller thought that a “compre­hensive dilated exam” could be billed with E/M code 99204. (Documenting the number of elements and dilation is something that could support use of the comprehensive Eye visit codes but do not fit the new E/M criteria.)
• Your practice automatically submits the exam code that your EHR system recommends. (If you are audited, it will be you—not your EHR vendor—who will be expected to justify the codes that were submitted.)

For most of 2021, Codequest courses took place virtually. Although attendees weren’t able to network in person, they still got to seek advice on their coding problems, including the examples below.

Cornea—an Extra Step for Transplant Complications

Problem. “We use T86.84 as the base ICD-10 code for corneal transplant complications, with a sixth character appended to add more detail—0: trans­plant rejection; 1: transplant failure; 2: transplant infection; 8: other complica­tions; or 9: unspecified complication. Recently, payers started denying our claims.”

Solution. Each year, CMS publishes a list of ICD-10 codes that is organized alphanumerically. The 2021 version of this list updated T86.84, adding a seventh character for laterality: 1: right eye; 2: left eye; 3: bilateral; or 9: unspec­ified eye. Federal payers would have implemented these changes on Oct. 1, 2020, but other payers may have been slower to do so. To stay current on the diagnosis codes, see “Use These ICD-10 Resources.”

Retina—Documenting the Need for PDT

Problem. “Our practice was unaware that photodynamic therapy (PDT) has a National Coverage Determination (NCD) instead of a Local Coverage Determination (LCD). The NCD details documentation requirements, which our practice had not implemented.”

Solution. The Academy has created a checklist to help you tick off all the NCD’s boxes, including a requirement that is often missing in documentation—evidence of classic choroidal neovascular membrane on fluorescein angiogram. (See “Fact Sheet for Doc­umenting the Need for Photodynamic Therapy,” Savvy Coder, May 2021 at aao.org/practice-management/coding/savvy-coder.)

E/M Versus Eye Visit Codes—a Lot Changed Last January

Problem. “Our practice almost exclu­sively uses Eye visit codes. We were not fully aware of CMS changes in allowables for E/M versus Eye visit codes or the ease of using the new E/M criteria, and we needlessly continued our ticking of boxes for the history and exam.”

Solution. The documenta­tion requirements that we didn’t like about E/M for the past 20+ years disap­peared on Jan. 1, 2021. Office-based levels of E/M are deter­mined by the level of medical deci­sion-making or by physician time on the date of the encounter (aao.org/em). Finally, E/M documentation is the way it should have been all along.

Screening Tests—not Billable Even When Pathology Is Found

Problem. “In error, we were told that when new patients come to the practice, we can perform several tests before they are examined by the physician. That way, when the physician examines the patient, she already has the test data at hand. We didn’t know that these are screening tests and as such are never billable to the payer.”

Solution. Implement an insurance-compliant protocol: All new patients must be examined by the physician and then the physician determines which test(s) are medically relevant to perform or delegate to staff. Standing orders and/or screening tests are never billable to the payer. If you are audited, the payer would recoup payment if you had billed such tests, even when pathol­ogy was found.

Vision Exam or Medical Exam—Check Your Payer’s Policy

Problem. “We don’t participate with vision plans—and historically, we primarily submitted Eye visit codes. Re­cently such claims were denied and the patients were responsible for payment. This makes for unhappy patients.”

Solution. Even outside of vision plans, commercial payers often only allow the use of Eye visit codes for vision exams, with diagnoses such as myopia, hyperopia, and presbyopia. For such payers, bill medical exams with the appropriate level of E/M code.

Cosurgery—When You Can and Can’t Use Modifier –62

Problem. “I just learned that our biller uses the cosurgery modifier (–62) when two surgeons each perform their part of a complicated case and submit different CPT codes.”

Solution. Under Medicare rules, cosurgery occurs when “the individual skills of two surgeons are necessary to perform a specific surgical procedure or distinct parts of a surgical procedure (or procedures) on the same patient during the same operative session.” Ophthalmic instances of this would generally involve two specialists each performing separate components of a surgical case and submitting the same CPT code. The Office of Inspector General is currently examining the use of modifier –62. (To learn more about modifier –62, read “Modifier –62: How to Determine Whether You Can Bill for Cosurgery,” Savvy Coder, May 2020 at aao.org/practice-management/coding/savvy-coder.)

A/R—Are You Below Par?

Problem. “I had no idea our claims denial rate was so high and that our accounts receivable (A/R) figures were so poor compared with other practices, according to benchmarking data from the AAOE’s AcadeMetrics [aao.org/academetrics].”

Solution. Return to the basics and really get to know your numbers. Evaluate your registration process; establish procedures for clean claim submissions; check that payments are posted prompt­ly; review your process for addressing denied claims; and resolve outstanding balances within 24 hours. You also should review and address credit bal­ances monthly.