Question: What do I do when I receive a comparative billing report?

Answer: The Centers for Medicare & Medicaid Services (CMS) has contracted with a company called RELI Group to notify ophthalmologists that their billing differ from their peers within the state and/or across the United States. The billing report does not separate out each subspecialty taxonomy code. These comparative billing reports (CBRs) that ophthalmologists are currently receiving focus on the Eye visit codes 92002, 92004, 92012 and 92014. Download an example of a CBR (PDF 146 KB).

Ophthalmologists are not required to respond to the CBR, as it is not an automatic indication that an audit of records will follow, but that some physicians may need additional review and education. You should, however, perform these steps to ensure that you are audit-ready.

• Read the CBR thoroughly and take it seriously.
• Often this is the warning shot that if the pattern of utilization continues, an audit is guaranteed.
• Make sure you are submitting from the proper family of exam codes.
• Many report Eye visit codes when the E/M equivalent actually has a higher allowable.
• Conduct your own internal chart audit to assure compliance.
• Pull a small sampling of records from each of the levels of codes where you are an outlier.
• Physician identifiable signature
• For paper records, the signature must be identifiable. If not, submit a signature log.
• For EHR, the physician signature must be secure. Note that the payer may request your EHR signature protocol.
• Is each page of the chart note identifiable with patient name, chart or ID number and date of service?
• If you are using a paper chart, is the writing legible? If not, dictate.
• Remember, the elements of the exam performed for both E/M and Eye visit codes must be medically relevant.
• Never copy-forward, copy-paste history or exam elements. Payment is for the work performed today.
• The primary diagnosis should relate to the chief complaint.
• Report the ICD-10 code(s) to the highest level of specificity.
• Only report diagnosis codes that pertain to today’s exam.
• If documentation meets the level of exam billed – celebrate. If not, use Academy resources and/or contact Academy consultants for a professional audit and customized coding education.