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Comparative Billing Report on Skilled Nursing Facility Billing Practices
Provided by NPI 1111111111
Introduction
Healthcare providers have a front line role in assisting the Centers for Medicare & Medicaid Services (CMS) in
effectively managing Medicare resources. CMS acknowledges the daily challenges providers face in serving
Medicare beneficiaries and the complexity of accurate billing for those services. The information contained in
Comparative Billing Reports (CBRs) is provided as a collaborative effort between the Medicare provider community
and the Centers for Medicare & Medicaid Services to support best billing practices and effective management of
Medicare program resources.
According to the 2010 Office of Inspector General (OIG) report, Questionable Billing by Skilled Nursing Facilities
(SNFs), from 2006 to 2008 the percentage of resource utilization groups (RUGs) for ultra high therapy increased
from 17 to 28. Billing for RUG codes with high activities of daily living (ADL) scores increased from 30 percent in
2006 to 34 percent in 2008. Even though SNFs significantly increased their billing for these higher paying RUG
codes, beneficiaries’ ages and diagnoses at admission were largely unchanged from 2006 to 2008. The OIG identified
billing patterns which indicated that certain SNFs may be routinely placing beneficiaries into higher paying RUG
codes regardless of the beneficiaries care and resource needs. Providers are responsible for ensuring that the RUG
codes they submit accurately reflect the level of services that are medically necessary and rendered.
The billing data and references in this report can assist you in performing a self-audit in assessing your conformity
with Medicare guidelines for billing RUG codes. The report also provides an opportunity for comparing your billing
practices to other SNFs billing for these services. We hope you find this information helpful and that it will provide
insights into your current and future billing practices. Listed below are website references pertinent to this CBR:
Questionable Billing by Skilled Nursing Facilities
http://oig.hhs.gov/oei/reports/oei-02-09-00202.pdf
Section 1812(a)(2)(A) of the Social Security Act
http://www.ssa.gov/OP_Home/ssact/title18/1812.htm
Section 1833(e) of the Social Security Act
http://www.ssa.gov/OP_Home/ssact/title18/1833.htm
Section 1862(a)(1)(A) of the Social Security Act
http://www.ssa.gov/OP_Home/ssact/title18/1862.htm
42 Code of Federal Regulations (CFR), Sections 409.30-409.32
http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-part409.pdf
Methodology
The analyses for this CBR are based on Medicare final claims data, with service dates from January 1, 2011 through
December 31, 2011, retrieved from the Integrated Data Repository (IDR) on July 27, 2012. Claims selected have paid
amounts greater than zero, are billed by SNFs with a bill class code equal to inpatient, have a revenue code equal to
0022 (SNF Prospective Payment System), and have the following RUG categories and codes equal to:
-
Rehabilitation Plus Extensive Services: RUX, RUL, RVX, RVL, RHX, RHL, RMX, RML, & RLX
Rehabilitation: RUC, RUB, RUA, RVC, RVB, RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, & RLA
The utilization measures analyzed in this CBR are: (1) the percentage of beneficiaries billed by therapy level
grouping among the rehabilitation plus extensive services category for your SNF, (2) the percentage of beneficiaries
billed by therapy level grouping among the rehabilitation services category for your SNF, and (3) the percentage of
beneficiaries billed for ultra high RUG codes among all therapy RUG codes for your SNF. The results are displayed
in graphs and tables. The therapy level groupings for each RUG category are displayed below. These measures will
be statistically compared to the average of your CMS region and national peers. CMS regions are defined on CMS
website at http://www.hhs.gov/about/.
CBR No. CBR019-1111111111
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Page 1 of 4
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Therapy Level
Grouping
Ultra High
Very High
High
Medium
Low
Rehabilitation Plus Extensive
Services RUG Codes
RUX, RUL
RVX, RVL
RHX, RHL
RMX, RML
RLX
Rehabilitation RUG Codes
RUC, RUB, RUA
RVC, RVB, RVA
RHC, RHB, RHA
RMC, RMB, RMA
RLB, RLA
Results
Figure 1 below displays the percentage of beneficiaries billed by therapy level grouping by you among the
rehabilitation plus extensive services category and the average percentage of beneficiaries billed per therapy level
grouping by your region and the nation. Table 1, following this figure, shows the statistical significance of the visual
differences.
90.0%
Figure 1. Percentage of Beneficiaries Billed by Therapy Level Grouping
Among the Rehabilitation Plus Extensive Services Category for Your SNF and
the Average Percentage for Your Region and the Nation, 2011
83.6%
80.0%
70.0%
Percent
60.0%
50.0%
53.2%
You
Region
Nation
45.3%
36.5%
40.0%
28.5%
30.0%
20.0%
14.8% 15.2% 15.9%
10.2%
5.0%
10.0%
1.4%
N/A
5.3%
8.6%
0.2%
0.0%
Ultra High
Very High
High
Medium
Low
Table 1 below shows the results of the statistical comparison of the percentage of beneficiaries billed per therapy
level grouping by you among the rehabilitation plus extensive services category and the average percentage of
beneficiaries billed per therapy level grouping by your region and the nation. A statistical test was used to determine
if there was a significant difference between the percentage of beneficiaries per therapy level grouping billed by you
and the average percentage of beneficiaries by your region and the nation.
Table 1. Statistical Comparison of the Percentage of Beneficiaries Billed by Therapy Level Grouping Among
the Rehabilitation Plus Extensive Services Category for Your SNF to the Average Percentage for Your Region
and the Nation, 2011
You
CMS Region 1
Nation
Therapy
Level Group Percent
Percent
Difference
Significance*
Percent Difference Significance*
Ultra High
Very High
High
Medium
Low
83.6%
N/A
14.8%
1.4%
0.2%
45.3%
28.5%
15.2%
10.2%
5.3%
38.3%
N/A
-0.4%
-8.8%
-5.1%
higher
N/A
within the norm
lower
lower
53.2%
36.5%
15.9%
5.0%
8.6%
30.4%
N/A
-1.1%
-3.6%
-8.4%
higher
N/A
lower
lower
lower
* A t-test was used in this analysis; a p value ≤ 0.05 indicates that we are at least 95% confident that the difference is significant. If a peer group has less than 30
SNFs, a t-test comparison was not performed and your significance will be listed as “N/A.” Alternately, if your significance is “N/A” and your percent is also
“N/A,” a t-test was not performed because you did not bill any services and are not part of the peer group.
CBR No. CBR019-1111111111
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Figure 2 below displays the percentage of beneficiaries billed by therapy level grouping by you among the
rehabilitation services category and the average percentage of beneficiaries billed by therapy level grouping by your
region and the nation. Table 2, following this figure, shows the statistical significance of the visual differences.
Figure 2. Percentage of Beneficiaries Billed by Therapy Level Grouping Among
the Rehabilitation Services Category for Your SNF and the Average Percentage
for Your Region and the Nation, 2011
80.0%
70.2%
70.0%
60.0%
55.0%
49.9%
Percent
50.0%
You
Region
40.0%
Nation
30.0%
25.6%
25.5%
22.6%
19.7%
20.0%
14.3%
10.0%
3.2%
5.5% 5.3%
5.3% 5.0%
1.0%
N/A
0.0%
Ultra High
Very High
High
Medium
Low
Table 2 below shows the results of the statistical comparison of the percentage of beneficiaries billed per therapy
level grouping by you among the rehabilitation services category and the average percentage of beneficiaries billed
per therapy level grouping by your region and the nation. A statistical test was used to determine if there was a
significant difference between the percentage of beneficiaries per therapy level grouping billed by you and the
average percentage of beneficiaries by your region and the nation.
Table 2. Statistical Comparison of the Percentage of Beneficiaries Billed by Therapy Level Grouping Among
the Rehabilitation Services Category for Your SNF to the Average Percentage for Your Region and the
Nation, 2011
You
CMS Region 1
Nation
Therapy
Level Group
Percent
Percent
Difference
Significance* Percent Difference Significance*
Ultra High
Very High
High
Medium
Low
70.2%
25.6%
3.2%
1.0%
N/A
55.0%
22.6%
19.7%
5.3%
5.5%
15.2%
3.0%
-16.5%
-4.3%
N/A
higher
higher
lower
lower
N/A
49.9%
25.5%
14.3%
5.0%
5.3%
20.3%
0.1%
-11.1%
-4.0%
N/A
higher
within the norm
lower
lower
N/A
* A t-test was used in this analysis; a p value ≤ 0.05 indicates that we are at least 95% confident that the difference is significant. If a peer group has less than 30
SNFs, a t-test comparison was not performed and your significance will be listed as “N/A.” Alternately, if your significance is “N/A” and your percent is also
“N/A,” a t-test was not performed because you did not bill any services and are not part of the peer group.
CBR No. CBR019-1111111111
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information intended for listed provider’s view only.
Page 3 of 4
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Figure 3 below displays the percentage of beneficiaries billed for ultra high RUG codes among all therapy RUG
codes by you and the average percentage of beneficiaries billed for ultra high RUG codes in your region and the
nation. Table 3, following this Figure, shows the statistical significance of the visual differences.
Figure 3. The Percentage of Beneficiaries Billed for Ultra High RUG Codes
Among All Therapy RUG Codes for Your SNF and the Average Percentage for
Your Region and the Nation, 2011
80.0%
73.6%
70.0%
60.0%
52.2%
Percent
50.0%
44.5%
You
40.0%
Region
Nation
30.0%
20.0%
10.0%
0.0%
Ultra High
Table 3 below shows the results of the statistical comparison of the percentage of beneficiaries billed for ultra high
RUG codes among all therapy RUG codes by you to the average percentage of beneficiaries in your region and the
nation. A statistical test was used to determine if there was a significant difference between the percentage of
beneficiaries billed for ultra high RUG codes among all therapy RUG codes by you and the average percent of
beneficiaries in your region and the nation.
Table 3. Statistical Comparison of the Percentage of Beneficiaries Billed for Ultra High RUG Codes Among
All Therapy RUG Codes for Your SNF to the Average Percentage of Your Region and the Nation, 2011
You
Therapy
Level Group
Ultra High
CMS Region 1
Nation
Percent
Percent
Difference
Significance*
73.6%
52.2%
21.4%
higher
Percent Difference Significance*
44.5%
29.1%
higher
* A t-test was used in this analysis; a p value ≤ 0.05 indicates that we are at least 95% confident that the difference is significant. If a peer group has less than 30
SNFs, a t-test comparison was not performed and your significance will be listed as “N/A.” Alternately, if your significance is “N/A” and your percent is also
“N/A,” a t-test was not performed because you did not bill any services and are not part of the peer group.
Contact Information
Please direct all questions on the CBR content or any suggestions to the CBR Producer at (530) 896-7080. For
additional information, see www.cbrservices.com.
Please direct all mailing address changes to the CBR Disseminator at (888) 313-9666 or www.cbrcontactupdate.com.
CBR No. CBR019-1111111111
The contents of this document contain sensitive, personally identifiable
information intended for listed provider’s view only.
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