Using Comparative Billing Reports (CBRs) to Reduce CERT Errors

Incorrect coding of Evaluation and Management (E/M) services continues to account for a significant portion of WPS Medicare's Comprehensive Error Rate Testing (CERT) errors. As the Medicare contractor for this jurisdiction, WPS Medicare is required to correct problems that have been identified by the CERT Contractor.

E/M services should be performed and billed at the level which is medically necessary for the patient, and should be documented accordingly in the medical records. Because the nature of the patient's presenting problem(s) will vary, so will the amount of work necessary to address these problems. While there are variations among specialties and patient populations, billing patterns for each individual provider's E/M services within a specific E/M category are expected to reflect different service levels.

In a proactive measure to reduce the potential for future CERT error findings, WPS Medicare is analyzing provider billing patterns for E/M services. This analysis focuses on identifying providers who bill one E/M code within a category of E/M codes at a very high rate. Identified providers are sent an educational letter and Comparative Billing Report (CBR) to illustrate our findings. Providers who fail to modify their billing pattern post-education, or to provide a valid explanation for this variance, may be the subject of a probe review or a referral to another Medicare Contractor.

If you bill Evaluation and Management services to Medicare, we recommend that you perform a self-audit of your billing and documentation practices to ascertain if problem areas exist which may warrant further education or corrective actions. WPS Medicare will continue to monitor providers for potential billing aberrancies in order to reduce CERT error rates as required by the Centers for Medicare and Medicaid Services (CMS).

For more information on proper billing and documentation of these services, refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12Adobe Portable Document Format, Section 30.6 - Evaluation and Management Service Codes - General (CPT Codes 99201-99499).

Visit the WPS Medicare Evaluation and Management page for articles, additional CMS resources, and Frequently Asked Questions (FAQs) to assist you in the proper documentation and billing of these services.

Page Last Updated: Friday, 06-Apr-2012 08:01:30 CDT