CBR001-010 Frequently Asked Questions
General FAQs
Q: What is CBR?
A: A comparative billing report is developed in an effort to provide education to the provider community by comparing billing practices among you and your peer group.
Q: Why am I getting this report?
A: In an effort to reduce improper payments, CMS implemented an education process for the providers.
Q: What is the policy reference for this report?
A: The policy references can be found under the reference link section and within the CBR.
Q: Can I get specific claim data related to this report?
A: All the specific information related to the CBR report is listed under the methodology section in your report. Keep in mind that the data being provided is for educational purposes only.
Q: I have a question about my claims.
A: The Medicare Administrative Contractor (MAC) can assist you with questions about a specific claim.
Q: The address on the letter is no longer current; can you correct your files?
A: You can correct your address with the CBR disseminator, please see cover letter for the contact information. This will not correct your address with Medicare, please contact your MAC directly to change your address.
Q: I did not receive a comparative billing report. Would I be able to sign up to receive one?
A: We do not currently have a CBR subscription list. A comparative billing report is sent only to a specified study sample, with a maximum sample size of 5,000 providers. SGS is currently working with CMS to evaluate the capability of producing ad hoc requests for CBRs in the future.
Q: Is there a sample CBR that I can view?
A: Yes, a sample is provided for each CBR produced. Please see the CBR sample page.
Q: Can I suggest a topic to study?
A: We appreciate your suggestions for additional study topics. Please submit your study topic suggestions using the CBR Support Information Request Form.
Q: I am a hospital. Would I be able to receive this report?
A: No, hospitals will not receive a comparative billing report. Hospital-related comparative reports are performed for CMS by TMF and are known as PEPPER reports.
Q: What is a T-Test? What does it mean?
A: For the measures that are statistically compared, a statistical test called the 't-test' will be used to determine if a statistically significant difference between the individual provider and the state and national peer group exists. The 't-test' will generate a p-value for each comparison.
Q: What is a P-Value? What does it mean?
A: A difference in the utilization measure between a provider and the two peer groups with a p-value < 0.05 indicates that there is at least 95% confidence that the difference is significant. There are three outcomes to the 't-test'; 1) the individual provider's utilization measure is significantly higher, 2) lower, or 3) within norm compared to that of the peer groups. The results of statistical test for each measure will be displayed in a table.
Q: What is the difference between the Figure and the Table?
A: The Figure is a graphic representation of the same data represented in the Table. Additionally, the Table shows the difference and the statistical significance of the provider's data in comparison to their peers.
CBR009 Ordering Durable Medical Equipment: Diabetic Supplies FAQs
Q: Why are we getting this report?
A CBR was created for ordering Providers of diabetic supplies as a proactive tool to help prevent improper billing.
Q: Why was this topic chosen?
Diabetic Supplies has been identified as a vulnerability in the Medicare Program. CMS (Center for Medicare and Medicaid Services) recommended a comparative study be done. Ordering Providers play an important role in this process by writing accurate and complete orders, and understanding the guidelines associated with durable medical equipment (DME).
Q: How are the peers defined?
A single ordering provider will be identified by NPI. The peer groups for comparison with the individual referring provider are:
- State: All providers ordering diabetic supplies who practice in the individual provider's state. The ordering provider's practice state will be identified through the National Plan and Provider Enumeration System (NPPES) Downloadable File (as of May 9, 2011) or the IDR.
- National: All providers ordering diabetic supplies in the nation.
Q: How was the data obtained for this report?
The analysis for this CBR encompassed all Medicare DME final claims with dates of service from January 1, 2010 through December 31, 2010 that were retrieved from the Integrated Data Repository (IDR) on July 18, 2011 and meet the criteria listed below:
- HCPCS codes: A4253, A4256, A4258, and A4259
- Paid claim lines only
- Ordering providers who had greater than zero dollars paid for any of the HCPCS codes mentioned above.
- Providers whose NPI is still active according the NPI Registry as of May 9, 2011.
The table below displays the description of each of the HCPCS codes:
| HCPCS Code | HCPCS Code Description |
|---|---|
| A4253 | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
| A4256 | Normal, low and high calibrator solution / chips |
| A4258 | Spring-powered device for lancet, each |
| A4259 | Lancets, per box of 100 |
The table below displays the description of the modifiers used in this CBR:
| Modifier Code | Modifier Description |
|---|---|
| KX | Specific required documentation on file |
| KS | Glucose monitor supply for diabetic beneficiary not treated by insulin |
Q: Where can additional information be found regarding Medicare guidelines on Ordering Durable Medical Equipment for Diabetic Supplies?
- References are listed on page 1 and 2 of the Comparative Billing Report
- References are listed under recommended links on this website
- From your DME Medicare Administrative Contractor (MAC)
- From the CMS website
CBR007 Ordering Durable Medical Equipment: Spinal Orthotics FAQs
Q: Why are we getting this report?
A: A CBR was created for ordering Providers of spinal orthotics as a proactive tool to help prevent improper billing.
Q: Why was this topic chosen?
Spinal orthotics has been identified as a vulnerability in the Medicare Program. CMS (Center for Medicare and Medicaid Services) recommended a comparative study be done. Ordering Providers play an important role in this process by writing accurate and complete orders, and understanding the guidelines associated with durable medical equipment (DME).
Q: How are the peers defined?
A single ordering provider will be identified by NPI. The peer groups for comparison with the individual ordering provider are:
- State: All ordering providers who practice in the individual provider's state. The ordering provider's practice state will be identified either through the National Plan and Provider Enumeration System (NPPES) Downloadable File (as of March 14, 2011) or the IDR.
- National: All ordering providers in the nation.
- State/Specialty: All ordering providers who practice in the individual provider's state and have the same specialty. The ordering provider's practice state and specialty are identified through the NPPES Downloadable File (as of May 9, 2011).
- Specialty: All ordering providers in the nation who have the same specialty.
Q: How was the data obtained for this report?
The analysis for this CBR will encompass all Medicare DME final claims data with dates of service from January 1, 2010 through December 31, 2010 that were retrieved from the Integrated Data Repository (IDR) on May 24, 2011 and meet the criteria listed below:
- HCPCS codes: L0630, L0631, L0633, and L0637.
- Denied and paid claims.
- Ordering providers who had greater than zero dollars paid for any of the HCPCS codes mentioned above.
The table below displays the description of each of the HCPCS codes:
| HCPCS Code | HCPCS Code Description |
|---|---|
| L0630 | Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment |
| L0631 | Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment |
| L0633 | Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment |
| L0637 | Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment |
Q: Why were these codes for spinal orthotics chosen and what is the correlation between L0630 and L0631 and L0633 and L0637?
A review of Medicare billings for Spinal Orthotics determined that Medicare payments for lumbar-sacral orthotics significantly increased throughout calendar year 2010. An examination of the four procedure codes associated with the lumbar-sacral orthotic devices listed above indicates that L0630 is a similar but less complex and less costly device when compared to L0631. A comparable relationship exists between L0633 and L0637. A review of the ICD-9-CM diagnosis codes further determines that the devices are ordered for patients with similar underlying conditions. As a result, we present a comparison of the two sets of codes and encourage providers to ensure that the level of complexity of the device ordered is consistent with the medical needs of the patient.
Q: Explain why Figure 1 and Table 1 show "0" for my data.
If the CMS data shows that you ordered L0630 and did not order L0631, or visa versa, the respective code will be recorded as "0". Similarly, if you ordered L0633 and did not order L0637 or visa versa the respective code will be recorded as "0". If you did not order either of the grouped codes it will be recorded as N/A. (Refer to FAQ number 5 for explanation of the code groupings)
Q: Explain the use of N/A in the "You" column of Table 2 and in Figure 3.
If the data showed you did not order a code it will be recorded as N/A.
Q: My specialty is recorded as "Other" in Figure 2. In Table 2, am I compared to my peers in the "Other" category or my individual specialty?
In Table 2, you will be compared to your individual specialty, as recorded in the NPI Registry.
Q: Where can additional information be found regarding Medicare guidelines on Ordering Durable Medical Equipment for Spinal Orthotics?
- References are listed on page 1 of the Comparative Billing Report
- References are listed under recommended links on this website
- From your DME Medicare Administrative Contractor (MAC)
- From the CMS website
CBR006 Sleep Study FAQs
Q: Why are we getting this report?
A CBR was created for Sleep Study Providers as a proactive tool to help prevent improper billing.
Q: Why was this topic chosen?
Sleep study services have been identified as a vulnerability in the Medicare Program. CMS (Center for Medicare and Medicaid Services) recommended a comparative study be done.
Q: How are the peers defined?
A single sleep study service provider will be identified by NPI. The peer groups for comparison with the individual sleep study service provider are:
- Geographic Area (Urban, Rural, and Super Rural): The providers were grouped into one of three geographic areas. The geographic areas are determined by CMS using metropolitan statistical areas (MSAs) as defined by the Executive Office of Management and Budget. The three geographic areas are used in developing the Medicare Fee Schedule.
In order to reference the CMS geographical areas:
CMS file "2010 End of Year Zip Code"
End of Year Zip Codes
http://www.cms.gov/FeeScheduleGenInfo/ - National: All sleep study service providers in the nation.
Q: How was the data obtained for this report?
The analysis for this CBR will encompass all Medicare Part B final claims data with dates of service from July 1, 2009 through June 30, 2010 that were processed by November 2010 and meet the criteria listed below:
- HCPCS/CPT codes: 95805, 95806,95807,95808,95810 and 95811 for attended/unattended sleep studies; and G0398, G0399 and G0400 for home unattended sleep studies.
- Paid and denied claims
The table below displays the description of each of the CPT codes:
| HCPCS/CPT Code | HCPCS/CPT Code Description |
|---|---|
| 95805 | Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretations of physiological measurements of sleep during multiple trials to assess sleeplessness. |
| 95806 | Sleep study, unattended, simultaneous recording of: heart rate, oxygen saturation, respiratory airflow, and respiratory effort. |
| 95807 | Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist. |
| 95808 | Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist. |
| 95810 | Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist. |
| 95811 | Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist. |
| G0398 | Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation. |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation. |
| G0400 | Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels. |
Q: Explain the use of "0" and "N/A" in Figure 1 and Table 1 for my data.
A: If the CMS data shows that you did not bill these codes from July 1, 2009 through June 30, 2010 that were processed by November 2010 it was recorded as "0" in Figure 1. In Table 1, lack of billing data is recorded as "N/A".
Q: Explain the use of N/A and "0" in Tables 3 and 4.
A: If your number is recorded as “N/A” that means that you did not bill that CPT code from July 1, 2009 through June 30, 2010. In Table 3, if your number is recorded as "0" you billed that CPT code <3 times for each of the beneficiaries that you billed from July 1, 2009 through June 30, 2010. In Table 4, if your number is recorded as "0" you billed that CPT code <2 times for each of the beneficiaries that you billed from July 1, 2009 through June 30, 2010.
Q: Where can additional information, regarding Medicare guidelines for Sleep Study Services billing, be found?
A:
- References are listed on page 5 of the Comparative Billing Report
- References are listed under recommended links on this website
- From your Medicare Administrative Contractor (MAC)
- From the CMS website
CBR005 Podiatry FAQs
Q: Why are we getting this report?
A CBR was created for Podiatry Providers as an educational tool to help prevent improper billing.
Q: Why was this topic chosen?
Podiatry services have been identified as a vulnerability in the Medicare Program. CMS (Center for Medicare and Medicaid Services) recommended a comparative study be done.
Q: How are the peers defined?
A single podiatry provider will be identified by NPI. The peer groups for comparison with the individual podiatrist are:
- State: All podiatrists who practice in the individual provider's state. If a provider practices in more than one state, he/she is compared to the podiatrists in the state where he/she has the majority of his/her business.
- National: All podiatrists in the nation.
Q: How was the data obtained for this report?
The data is retrieved from the National Claims History (NCH) data base at CMS. The analysis for this CBR will encompass all Medicare Part B podiatry provider final claims data with dates of service from July 1, 2009 through June 30, 2010 that are processed by November 2010 and meet the criteria listed below:
- CPT codes: 11720 and 11721 for nail debridement; and 99212, 99213, 99214, 99215, 99307, 99308, 99309, and 99310 for evaluation and management (E/M)
- Place of Service codes: 11 (office) and 31 (skilled nursing facility; SNF)
- Provider Specialty Code = 48
- Paid and denied claims
The table below displays the description of each of the CPT codes:
| CPT Code | CPT Code Description |
|---|---|
| 11720 | Debridement of nail(s), one to five |
| 11721 | Debridement of nails, six or more |
| 99307 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; and straightforward medical decision making |
| 99308 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; and medical decision making of low complexity |
| 99309 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed problem focused examination; and medical decision making of moderate complexity |
| 99310 | Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a comprehensive interval history; a comprehensive examination; and medical decision making of high complexity |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; and straightforward medical decision making |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed problem focused examination; and medical decision making of moderate complexity |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity |
The table below displays the description of each of the two Place of Service (POS) codes:
| POS Code | POS Code Description |
|---|---|
| 11 | Office |
| 31 | Skilled Nursing Facility |
Q: Why do I have n/a in the Significance* column in Table 2?
If there were less than 30 Providers in your state that billed this CPT code during the stated time frame, a T-test comparison could not be performed.
Q: Why do I have "0" for my data in Figure 3?
If you did not bill in the Skilled Nursing Facility (SNF) setting and/or the office setting the data will be recorded as "0".
Q: What codes were used to generate the data in Figure 3 and Table 3?
Nail debridement, CPT codes 11720 and 1172, were used in Figure 3 and Table 3. (This is explained earlier in the Methodology section of the report.)
Q: Explain why Table 3 shows n/a in the Significance* column for SNF: Max # of Benes and Office: Max # of Benes? (May say: SNF: Max # Benes and Office: Max # Benes)
The significant difference was not calculated for the maximum number of beneficiaries in the skilled nursing facility (SNF) and the office settings; therefore n/a was placed as a place holder. In other words, since the Max # is the provider's actual Max # a statistical significance does not apply.
Q: Where can additional information, regarding Medicare guidelines for Podiatry Services billing, be found?
- References are listed on page 1 of the Comparative Billing Report
- References are listed under recommended links on this website
- From your Medicare Administrative Contractor (MAC)
- From the CMS website
CBR004 Hospice FAQs
Q: Why are we getting this report?
A: A CBR was created for Hospice Providers as an educational tool to help prevent improper billing.
Q: Why was this topic chosen?
A: Hospice services have been identified as a vulnerability in the Medicare Program. CMS (Center for Medicare and Medicaid Services) recommended a comparative study be done.
Q: How are the peers defined?
A: A single hospice will be identified by NPI. The peer groups for comparison with the individual Hospice Providers are:
- CMS Region: All Hospice Providers who practice in the individual provider's region. If a provider practices in more than one region, they are compared to the Hospice Providers in both regions and receive a CBR for each region.
- Nation: All Hospice Providers in the nation
Q: How was it determined to do a CMS Region comparison?
A: In order to have a valid statistical comparison it was necessary to group hospice providers in larger groups than their states. The CMS Regions best met the criteria for geographical distribution.
The table and map below displays the CMS Regions:
| Region | States |
|---|---|
| 1 | Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont |
| 2 | New Jersey, New York, Puerto Rico, Virgin Islands |
| 3 | Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia |
| 4 | Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee |
| 5 | Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin |
| 6 | Arkansas, Louisiana, New Mexico, Oklahoma, Texas |
| 7 | Iowa, Kansa, Missouri, Nebraska |
| 8 | Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming |
| 9 | Arizona, California, Hawaii, Nevada, Pacific Territories |
| 10 | Alaska, Idaho, Oregon, Washington |
Q: How was the data obtained for this report?
A: The analysis for this CBR will encompass all Medicare Part A Hospice Provider final claims data with claims from dates of service from January 1, 2009 through December 31, 2009 that are processed by July 2010 and meet the criteria listed below:
- NCH Claim Type Code = 50 (hospice claim)
- HCPCS codes: Q5001-Q5008
- Revenue codes: 0651, 0652, 0655, and 0656
- Paid and denied claims
The table below displays the description of each of the eight HCPCS codes:
| HCPCS Codes | HCPCS Code Description |
|---|---|
| Q5001 | Hospice care provided in patient's home/residence |
| Q5002 | Hospice care provided in assisted living facility |
| Q5003 | Hospice care provided in nursing long term care facility or non-skilled nursing facility |
| Q5004 | Hospice care provided in skilled nursing facility (SNF) |
| Q5005 | Hospice care provided in inpatient hospital |
| Q5006 | Hospice care provided in inpatient hospice facility |
| Q5007 | Hospice care provided in long term care hospital |
| Q5008 | Hospice care provided in inpatient psychiatric facility |
The table below displays the description of each of the four Revenue codes:
| Revenue Codes | Revenue Code Description |
|---|---|
| 0651 | Routine home care |
| 0652 | Continuous home care |
| 0655 | Inpatient respite care |
| 0656 | General inpatient care |
Q: Explain why some of the graphs and tables have no data.
A: If the Hospice Providers in this study did not bill a particular level of care and/or services in a particular care setting, the data was unavailable and no comparison will appear for that category.
Q: Where can additional information, regarding Medicare guidelines for hospice billing, be found?
A:
- References are listed on page 1 of the Comparative Billing Report
- References are listed under recommended links on this website
- From your Medicare fiscal intermediary (e.g. MAC, RHHI, or FI)
- From the CMS website
Q: Why wasn’t Q5009 used in the hospice CBR?
A: HCPCS code Q5009 is defined as "Care provided in a place not otherwise specified." This code was not used in the study because CMS chose to focus the comparative analyses on the four specific hospice care settings as shown in the CBR. In other words, we chose to focus on these 4 settings: home (Q5001, Q5002), skilled nursing facility (Q5003, Q5004), freestanding (Q5006), and inpatient (Q5005, Q5007, Q5008).
CBR003 Ambulance FAQs
Q: Why am I getting this report?
A: A CBR was created for the top 5,000 Ambulance Providers who provided Basic Life Support (BLS) services in 2009.
Q: Why was this topic chosen?
A: Non-Emergency Ambulance services have been identified as a vulnerability in the Medicare Program. CMS (Center for Medicare and Medicaid Services) recommended a comparative study be done.
Q: How are my peers defined?
A: A single Ambulance Provider will be identified by NPI. The peer groups for comparison with the individual Ambulance Providers are:
- State: All Ambulance Providers who practice in the individual provider's state. If a provider practices in more than one state, he/she is compared to the Ambulance Providers in the state where it has the majority of its business.
- Nation: All Ambulance Providers in the nation
Q: How was the data obtained for this report?
A: The data is from the National Claims History (NCH) at CMS (Center for Medicare and Medicaid Services). The analysis for this CBR will encompass all Medicare Part B ambulance provider final claims data with dates of service from January 1, 2009 through December 31, 2009 that are processed by July 2010 and meet the criteria listed below:
- Provider specialty equal to 59 - Ambulance
- HCPCS Codes: A0428 and A0429
- Depending on analysis: Modifier code that begins or ends with "G or J" and modifier code that ends with "E or R".
- Paid claims (to provider or any other party)
The table below displays the description of each of the two HCPCS codes:
| HCPCS Codes | HCPCS Description |
|---|---|
| A0428 | Ambulance service, Basic Life Support (BLS), non-emergency transport |
| A0429 | Ambulance service, basic life support (BLS), emergency transport |
Q: Can you further explain Figure 1 and Table 1?
A: The percentage of non-emergency and non-emergency, ESRD related transports are determined by adding the total number of BLS transports (A0428 and A0429) and dividing by the number of non-emergency transports or non-emergency ESRD related transports and multiplying by 100 to create a percentage. The importance of this information is to show providers how they compare to their state and national peers. If you vary from your peers, this may necessitate a self-audit to ensure you are in compliance with the Medicare Guidelines.
Q: How is "All" defined in Figure 2 and Table 2?
A: "All" is defined as all of the non-emergency BLS transports where the destination is a residence or residential, domiciliary or custodial facility. The "All" column is the sum of the non-ESRD and ESRD transports for the individual provider because raw numbers were used. The State and Nation categories are averages of the providers for that category and therefore independent calculations that will not be the sum of the non-ESRD and ESRD transports.
CBR002 and CBR010 Chiropractic Services FAQs
Q: Why are we getting this report?
For CBR 002: This CBR was created for the top 5,000 Chiropractors who billed services in 2009.
For CBR 010: A CBR was created for Chiropractors who billed services in 2010 as a proactive tool to help prevent improper billing.
Q: Why was this topic chosen?
Chiropractic services have been identified as a vulnerability in the Medicare program. CMS recommended a comparative study be done.
Q: How are my peers defined?
A single chiropractor will be identified by NPI. The peer groups for comparison with the individual chiropractors are:
- State: All chiropractors who practice in the individual provider's state. If a provider practices in more than one state, he/she is compared to the chiropractors in the state where he/she has the majority of his/her business.
- Nation: All chiropractors in the nation
Q: Is there a limit to the number of chiropractic services that I can get paid for?
No, Medicare does not have a cap/limit for covered chiropractic care. There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.
Section 1862(a)(1)(A) of the Social Security Act (SSA) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Q: Is maintenance care a covered service under Medicare?
As stated in part in the MLN Matters Number SE0749, Spinal manipulation is a covered service under Medicare, no matter which phase of care you may be in; however, maintenance care is not medically reasonable and necessary and therefore not reimbursable by Medicare. Acute, chronic, and maintenance adjustments are all "covered" services, but only acute and chronic services are considered active care and may, therefore, be reimbursable. Maintenance therapy is defined (per chapter 15, Section 30.5.B of the Medicare Benefits Policy Manual) as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.
Q: How was the data obtained for this report?
For CBR 002: The data is from the National Claims History (NCH) at CMS (Center for Medicare and Medicaid Services). The analysis for the Chiropractic Services CBR encompasses all Medicare Part B chiropractic provider final claims data with claims from dates of service from January 1, 2009 through December 31, 2009 that are processed by July 2010 and meet the criteria listed below:
- Provider specialty equal to 35-Chiropractic
- Office is the place of service
- CPT Codes:
- 98940 (chiropractic manipulative treatment; spinal, 1-2 regions)
- 98941 (chiropractic manipulative treatment; spinal, 3-4 regions)
- 98942 (chiropractic manipulative treatment; spinal, 5 regions)
- Paid and denied claims
For CBR 010: The analysis for this CBR will encompass all Medicare Part B chiropractic provider final claims data with claims from dates of service from January 1, 2010 through December 31, 2010 that were retrieved from the Integrated Data Repository (IDR) on August 31, 2011 and meet the criteria listed below:
- Provider specialty equal to 35-Chiropractic
- Office is the place of service
- CPT Codes:
- 98940 (chiropractic manipulative treatment; spinal, 1-2 regions)
- 98941 (chiropractic manipulative treatment; spinal, 3-4 regions)
- 98942 (chiropractic manipulative treatment; spinal, 5 regions)
- Paid and denied claims
Q: What does the word "distinct" mean in the context of the Chiropractic Services CBR?
The word "distinct" is used here as a statistical description meaning single or unique. A distinct beneficiary is a specific or individual beneficiary. A distinct diagnosis is a single or unique diagnosis.
Q: When calculating the average number of services billed per beneficiary (figure 1 and table 1), if a claim was billed multiple times for the same date of service (DOS) will the claim be counted more than once?
No, if a specific date of service was billed on multiple claims, it will only count once. Only the final claims were counted.
Q: Why were diagnoses codes 739.0-739.9 excluded from the analysis?
Because the subluxation level is a required field, we chose to focus study comparisons on the neuromusculoskeletal conditions and/or symptoms necessitating treatment. These diagnoses are listed in the secondary diagnoses field(s).
Q: In Figure 2 and Table 2, how were the groups of "number of distinct diagnosis" determined?
These groupings of 1-2, 3, and 4+ were data driven. In other words, 50% of the claims per beneficiary fell into the 1-2 distinct diagnosis group, 25% fell into the 3 distinct diagnosis group, and 25% fell into the 4+ distinct diagnosis group.
Q: Can you further explain Figure 2?
Figure 2 describes the number of beneficiaries, categorized by the number of distinct diagnoses (1-2, 3, and 4 or more) used throughout 2010, associated with you, your state, and national peers. In other words, it describes the number of distinctly different diagnoses that you billed for each beneficiary over the course of the year. This does not reflect the number of diagnoses used on an individual claim. The educational value of examining billing in this way is to shed light on whether providers are using pertinent and appropriate diagnoses that are associated with the patient's neuromuscular symptom/complaint experienced on that date of service. In addition, in a self-audit, you may determine that some diagnoses are pertinent to bill on the claim, whereas, other conditions may just need to be documented in your records. There is no right or wrong determination in Figure 2; it simply represents an opportunity for education.
For CBR 002: Q: Why are the rankings duplicated in Table 3?
Table 3 shows the top five diagnoses billed by you and your state and national peers in 2009. The distinct count of beneficiaries associated with each diagnosis is used to rank the diagnoses. In the top five diagnoses, some of the diagnoses had the same count of beneficiaries therefore the diagnosis tied for the ranking. Starting from the diagnosis ranked at one, every diagnosis with a tied rank will have the same rank number and the next diagnosis following the tie will have rank equal to the previous tie rank number plus the number of diagnoses tied at that rank number. You may also notice that a ranking numeral may have been skipped. We chose to count the duplicated ranking as the following number due to space considerations. Please see example below:
| Diagnosis | Number of Beneficiaries | Rank |
|---|---|---|
| A | 100 | 1 |
| B | 95 | 2 |
| C | 95 | 2 |
| D | 95 | 2 |
| E | 80 | 5 |
| F | 80 | 5 |
CBR001 and CBR008 Physical Therapists FAQs
Q: Why was this Topic chosen?
A: Outpatient Physical Therapy Services billed with the KX Modifier Provided by Independent Therapists was identified as a vulnerability to the Medicare Program.
Q: What was the Purpose?
A: The purpose of this CBR is to identify possible improper use of the KX Modifier when providing and billing for physical therapy services.
Q: When should KX Modifier be used?
A: Physical Therapy providers are instructed to use the KX Modifier to indicate that the services that they are rendering are: (1) medically necessary and that justification is documented in the medical records, (2) the physical therapy financial limitation cap has been met, and (3) that the beneficiary's condition is such that they require further treatment.
Q: Are there any websites I can go to for information regarding the CBR Report.
A: Please refer to the references found in your CBR or in the Recommended Links section of this website.
Q: Who are my peers?
A: In this instance, anyone billed with a Specialty code 65 (Independent outpatient Physical Therapist). Place of service billed: Office setting.
- State: All physical therapists who practice in the individual provider's state. If a provider practices in more than one state, he/she was compared to the physical therapists in the state where he/she has the majority of his/her business.
- National: All independent outpatient physical therapists in the nation.
Q: What are the definitions of the 5 codes used in the CBR?
A: The table below displays the description of each of the five HCPCS and CPT codes:
| Billing Codes | Procedure Code Description |
|---|---|
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97140 | Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes |
| G0283 | Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care |
Q: How was Table 1 calculated?
A: For CBR 001: Table 1: Percentage of Paid Services Rendered with the KX Modifier from January 2009 to March 2009 - For each of the five HCPCS codes, the percentage of paid services rendered with the KX Modifier of all paid services rendered between January 2009 and March 2009 will be calculated for the individual provider, the state peer group, and the national peer group. The percentage for the state and national peer group will be an average of the percentages of individual providers. Each claim line is counted as one service. The individual provider's percentage will be statistically compared to the average percentage of the state and national peers.
For CBR 008: Table 1: Percentage of Paid Services Rendered with the KX Modifier from January 2010 to March 2010 - For each of the five HCPCS codes, the percentage of paid services rendered with the KX Modifier of all paid services rendered between January 2010 and March 2010 will be calculated for the individual provider, the state peer group, and the national peer group. The percentage for the state and national peer group will be an average of the percentages of individual providers. Each claim line is counted as one service. The individual provider's percentage will be statistically compared to the average percentage of the state and national peers.
Q: How was Table 2 calculated?
A: For CBR 001: Table 2: Percentage of Paid Services Rendered with the KX Modifier in 2009 - For each of the five HCPCS codes, the percentage of paid services rendered with the KX Modifier of all paid services rendered in 2009 will be calculated for the individual provider, the state peer group, and the national peer group. The percentage for the state and national peer group will be an average of the percentages of individual providers. Each claim line is counted as one service. The individual provider's percentage will be statistically compared to the average percentage of the state and national peers.
For CBR 008: Table 2: Percentage of Paid Services Rendered with the KX Modifier in 2010 - For each of the five HCPCS codes, the percentage of paid services rendered with the KX Modifier of all paid services rendered in 2010 will be calculated for the individual provider, the state peer group, and the national peer group. The percentage for the state and national peer group will be an average of the percentages of individual providers. Each claim line is counted as one service. The individual provider's percentage will be statistically compared to the average percentage of the state and national peers.
Q: How many CBR's were generated?
A: For CBR 001: There were approximately 5,000 CBRs generated from 2009 claims data.
For CBR 008: There were approximately 5,000 CBRs generated from 2010 claims data.
Q: Can I just add the KX Modifier to all my therapy claims?
A: No, only when a beneficiary qualifies for a therapy cap exception should the provider add the KX Modifier to the therapy procedure code that is subject to the cap limits. By adding the KX Modifier to the procedure code, the provider is attesting that the services billed qualify for the cap exception as listed in the table in the Claims Processing Manual, Chapter 5, Section 10.2.C.6, 'Use of the KX Modifier for Therapy Cap Exceptions'; are reasonable and necessary services that require the skills of a therapist; and are justified by appropriate documentation in the patient's medical record.
Q: When should I submit documentation for a 'manual request'; of a therapy cap exception?
A: In 2006, Exception Processes fell into two categories, Automatic Process Exceptions, and Manual Process Exceptions. Beginning January 1, 2007, there is no manual process for exceptions. All services that require exceptions to caps shall be processed using the automatic process. All requests for exception are in the form of a KX Modifier added to claim lines. (See subsection C6 for use of the KX Modifier.) Also, use of the automatic process for exception does not exempt services from manual or other medical review processes as described in 100-08, Chapter 3, Section 3.4.1.1.1.
Q: I am a hospital-based physical therapist. Would I be able to receive this report?
A: No, hospital-based physical therapist are not included in this comparative billing report.