Comparative Billing Report From Medicare

Comparative Billing Reports (CBR’s) – You may have received one of these recently or will be in the coming weeks.  Several of the providers we work with have already done so.  The letter may show that your practice has been identified with an unusual billing pattern, specifically for CPT codes 93970 and 93971.

Well don’t panic (yet).  This is an informative report stating that the Office of the Inspector General (OIG) has focused on non-invasive vascular studies and their investigations have found that in the 20 highest use counties patients have received twice as many ultrasound services than in the rest of the country.  They further identified that among claims for CPT codes 93925, 93926, 93970, 93971 reviewed, 16% were found to be in error, and 100% of these errors were caused by insufficient documentation.

This letter lets you know that your practice falls into the high use range. (We encourage you to read this letter in its entirety if you receive one.)

Well of course you fall into a high use range, it is a phlebology practice after all.  However, a report of this nature does indicate that your ultrasound services may come under additional scrutiny, not excluding an audit.

Some specific issues found were:

–  Minimal documentation without a specific location and description of any signs or symptoms and their severity

–  Documentation of a rule out diagnosis instead of a specific indication

–  Documentation of unilateral medical necessity for a bilateral service

–  Incorrect rendering physician, among others

These issues are incidentally the ones we most commonly find when reviewing the ultrasound charting on a phlebology practice.  Prudent coding along with excellent charting should be the norm, but some internal review of your processes would be advised.

Noted above is the issue of billing for bilateral services instead of a unilateral/ limited service. In our article, which can be referenced at https://apfsbilling.com/2015/11/93970-vs-93971-usage-and-charting/, the difference between these codes is given in detail.

Briefly, 93970 is only to be utilized for a Bilateral Complete study.  Complete is the often less understood word here. To be complete you must image all deep and superficial veins in both legs to qualify for this code.  Not only do you need to image and report on each of these veins, but you also need to have a good reason to perform a study at this level of detail.

This is where the term Rule Out comes into play.  A rule out study cannot be billed to insurance.  So if a patient only has symptoms in the LT leg, a bilateral study cannot be ordered just to rule out the possibility of a condition in the right leg too.  After an initial diagnosis is obtained, and treatment has commenced, limited studies would be the only diagnostic services justifiable by the documentation. It would be a rare instance when another complete study would be needed.  Ordering any other way would be considered unnecessary.

In a world where following ingrained patterns is the norm, funneling all patients into the same diagnostic and treatment pathway is unfortunately all too common and an area that the medical provider needs to take extra caution. There are many resources available on proper ordering, documentation and rationale for diagnostic studies, some of which are included at the end of your CBR letter.  Having a comprehensive knowledge of these concepts is essential.