What is the purpose and value of a CBR?

In March 2021, Medicare sent Consolidated Billing Reports (CBR) to ophthalmologists and optometrists. The information in the CBR, based on Part B Medicare data, looked at eye codes (920xx) and compared the physician to a peer group who serve these beneficiaries. The reports suggest that higher-than-average utilization is improper. We are still seeing these reports being sent to our clients by Medicare and other payers.

Q. What is a CBR?

A. A Consolidated Billing Report (CBR) is a document prepared by a Medicare contractor (RELI Group, in this case) that compares a physician to a peer group of other like physicians who serve Part B Medicare beneficiaries. Prior to the current round of reports beginning in 2021, CBRs were last sent to ophthalmologists and optometrists about eye codes (920xx) in 2015.

RELI Group used three metrics to identify recipients of the report. The three metrics are:

1. Percentage of comprehensive eye examinations
2. Average allowed amount per claim
3. Average number of comprehensive eye examinations per beneficiary.

If any of these metrics, when compared to the state or national peer group, is ≥ the 90th percentile, it is judged to be “significantly higher” and triggers the CBR.

The criteria that RELI Group used for sending a CBR were that the physician:

• Has a score significantly higher compared to either state or national percentages in any of the three metrics
• Has at least 130 total beneficiaries with claims submitted for CPT codes 92004, 92014, and
• Has at least $17,200 in total allowed charges for CPT codes 92004, 92014.

The dates of service in the 2021 reports were Nov. 1, 2019 to Oct. 31, 2020. Importantly, the AMA’s coding guidelines for evaluation and management (E/M) services changed dramatically on Jan. 1, 2021, only a short time later, and created a preference for E/M codes over eye codes, a trend that continues. This shift in coding for office visits has the potential to minimize the import of a CBR for eye codes.

Q. How should we respond to a CBR?

A. While the CBR states that it is educational and requires no response, its contents suggest that Medicare Administrative Contractors (MACs), the HHS Office of Inspector General, CMS, and other payers believe that ophthalmologists do not bill appropriately for their services. The CBR implies, but does not directly state, that billing patterns that significantly differ from other ophthalmologists or optometrists are suspect, probably inappropriate, and should not continue. The cover letter to the CBR states, “… this CBR is not an indication or precursor to an audit … Selected providers, however, may be referred for additional review and education.”

A response including the following information would be appropriate. According to the 2020 Medicare Fee-For-Service Supplemental Improper Payment Data, ophthalmologists are among a very few providers within Part A and Part B Medicare who largely succeed in billing accurately (go.cms.gov/3IXLF1b ). Projected improper payments for ophthalmologists were $162 million, representing just 2.3% of the $7 billion estimate for all Part B providers. Optometry didn’t do as well, but its error rate of 6.9% was still lower than the error rate for all specialties of 8.1%. Appendix L of this report identifies the top 20 service-specific overpayment rates, and eye codes are not on this list.

Q. What is our takeaway?

A. At the present time, there are no MACs with local coverage policies or educational articles about eye codes. The only instructions on this topic are in CPT, and those have not changed in decades. At the beginning of 2021, when so much attention was focused on E/M coding, the eye codes received no attention whatsoever.

In the chart reviews that Corcoran Consulting Group has performed for our clients over 30 years, we find that office visits are miscoded or billed incorrectly about 30-40% of the time. Coding with E/M codes generally had higher error rates than eye codes. The HHS report on improper payments also identified significant problems with E/M codes, but not eye codes.

The CBR is unhelpful. It looks for improvements in claims accuracy when ophthalmologists can legitimately claim to be far more accurate than most other providers. It assumes that ophthalmologists are homogeneous groups when substantial intraspecialty differences render comparisons suspect. The focus of the CBR on a code set that does not have a meaningful error rate is a waste of time and money, whether from Medicare or other payers. OM

Suzanne L. Corcoran, COE is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .