Comparative Billing Report Identifies Special Stain Outliers

Approximately 5,000 individual providers of tissue exams by pathologists in August received a comparative billing report (CBR) that compared their billing patterns for immunohistochemistry (IHC) and special stains procedures with a national average of their peers. The providers were chosen because their billing pattern differed in some way from national billing patterns. The CBR was developed, issued, and disseminated by Palmetto GBA and eGlobalTech (eGT), a Centers for Medicare and Medicaid Services contractor specializing in providing services to the federal government. The report was disseminated by fax or regular mail with fax numbers or addresses obtained from the National Plan and Provider Enumeration System and Provider Enrollment, Chain and Ownership System. Providers should make certain their information in these databases is correct. While the CBR, identified as CBR201407, is meant as an educational tool that can alert providers to potential problems that could result in increased scrutiny, it can also be a tool used to identify providers that may be committing fraud or abuse. This particular CBR was focused on IHC and special stains to educate providers about the proper units of service to bill for the new Healthcare Common Procedure Coding System (HCPCS) level II codes that went into effect in January 2014. The codes used for this report are:

• 88305—Tissue exam by pathologist;
• 88312—Special Stains—group I, for microorganisms;
• 88313—Special Stains—group II, other than those for microorganism or enzymes; and
• 88342—IHC.

Sample CBR Allows Providers to Preview a Report A sample CBR is available to all providers as part of the education aspect of issuing CBRs. The sample report consists of mock (deidentified) data and includes the language and all other information that was provided to the 5,000 providers who received CBRs specific to their practice. The sample includes the same language that was included in the actual CBRs, which explains not only the results of the data analysis but also the various policies and regulations that govern billing for these procedures. The policies come from a variety of sources, including the Internet Only Manuals, the Correct Coding Initiative policy manual, and the Pathology Service Coding Handbook^®. The existing policies and documentation requirements are outlined for the reader. The report explains that “the information provided does not supersede or alter the coverage and documentation policies as outlined in the Medicare Administrative Contractor (MAC) local coverage determinations (LCDs) and Policy Articles.” It also instructs the reader to seek answers to specific questions from their local MAC. What Metrics Are Being Measured The report specifically examines billing for the above listed HCPCS codes performed on gastric and colon biopsies. The metrics are:

• Average allowed charges per episode of care;
• Average services per episode of care; and
• Percentage of episodes of care with an IHC or special stain.

The report lists the specific references for the various regulations, rules, audit reports, and LCDs used to make determinations about the data on the claims. The report examines claims with allowed services for the HCPCS codes with dates of service from Jan. 1, 2013, through Dec. 1, 2013. The population of claims was restricted to beneficiaries that had gastric biopsies on the same date of services as the pathology claims. The gastric services are identified with HCPCS. Episodes of care are defined as a provider’s distinct interaction with a beneficiary on a date of service. The average allowed charges were broken down by state and across the nation so a provider is compared to similar providers in their state as well as nationally. There are four possible outcomes for the comparison tables included in each report to a specific provider. Each table contains columns that identify the provider’s data and what they are being compared to. Here is an example from the sample report:

Average Allowed Services by CPT® Code Per Episode of Care January 1, 2013 - December 31, 2013
CPT® Code	Your Average Services Per Episode	Your State’s Average Services Per Episode	Comparison with Your State’s Average	National Average Services Per Episode	Comparison with the National Average
88305	1.70	1.99	Does Not Exceed	2.27	Does Not Exceed
88312	1.69	1.27	Significantly Higher	1.44	Higher
88313	1.74	1.35	Higher	1.74	Does Not Exceed
88342	N/A	1.35	N/A	1.44	N/A
Note: A t-test was used in this analysis, alpha = 0.05. Source: Sample comparative billing report.

  There is a table for each of the metrics mentioned previously in this article. The four possible outcomes for the comparison columns in each table are:

• Significantly Higher—Provider’s value is higher than the peer value and the statistical test confirms a significance;
• Higher—Provider’s value is higher than the peer value but the statistical test does not confirm a significance;
• Does Not Exceed—Provider’s value is not higher than the peer value; and
• N/A—Provider did not have any allowed charges in this category.

Other Resources for Providers In addition to the references embedded in a specific CBR and the sample report, eGT and Palmetto GBA have also provided a frequently asked questions (FAQ) file about this CBR at www.cbrinfo.net. The FAQ provides more links and detailed explanations about various aspects of the report and the methodology used to collect and analyze the data. eGT and Palmetto will hold a one-hour webinar on the comparative billing report Aug. 27 starting at 3 p.m. Eastern time. Recordings will be available five business days after the live presentation. What Is Next? If your practice or laboratory is one of the 5,000 that received a CBR on this topic, you should conduct a self-audit. eGT provides guidance on conducting such an audit on its Web site. The CBR is one of nine reports released so far this year covering a variety of topics from all disciplines in health care, and there are more to come. Even if your lab did not receive one of these CBRs, it should review the sample report and other related information and at least review coding and billing for the tests involved. Another action step for labs related to the CBR is to establish a protocol to monitor eGT for lab-related reports. Labs should also document these steps as part of their compliance program annual review and update. Takeaway: The CBR on immunohistochemistry and special stains is another example of the government using data to identify potential billing, coding, and utilization problems. Providers need to become familiar with such reports and develop policies addressing how to respond to them.