E/M Coding Makes OIG 2011 Work Plan

Posted on 21. Oct, 2010 by jennifer.godreau.

Make sure your postop office visit documentation measures up.

The OIG has once again set its sights on several new targets to go with the upcoming new year, and this time the feds will be double- and triple-checking your E/M documentation.

On Oct. 1, the OIG published its 2011 Work Plan, which outlines the areas that the Office of Audit Services, Office of Evaluations and Inspections, Office of Investigations, Office of Counsel to the Inspector General, Office of Management  and Policy, and Immediate Office of the Inspector General will address during the 2011 fiscal year. When the OIG targets an issue in its Work Plan, you can expect the agency to carefully review and audit sample claims of those services.

The Work Plan “describes the specific audits and evaluations that we have underway or plan to initiate in the year ahead considering our discretionary and statutorily mandated resources,” the document indicates.

On the agenda for next year, the OIG has indicated that its investigators will “review the extent of potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations.” The OIG also plans to hone in on whether payments

Continue Reading

Place-of-Service Codes Caused $13 Million in Overpayments

Posted on 31. Aug, 2010 by jennifer.godreau.

Double check POS 11 shouldn’t be 22 — or 24.

Entering your place-of-service (POS) number on your claim form may seem routine, but a recent OIG audit found that practices are not giving POS numbers the care they deserve.

Based on a review of 100 non-facility Part B claims from 2007, the OIG found that only 10 of the sampled claims had the correct POS code assigned to it, resulting in overpayments of over $4,700. Based on the sample, the OIG estimated that Medicare nationally overpaid physicians $13.8 million in POS coding errors, according to the report.

Physicians collect higher payments for services rendered in the physician’s office, a patient’s home, an ASC, a nursing facility, or another non-hospital facility versus those services performed in a facility setting (such as a hospital). The OIG review of 100 sample claims found that 90 of the services were coded as having been performed in a non-facility location, even though

Continue Reading

Compliance: Curb Upcoding Mistakes Or Risk OIG Scrutiny

Posted on 08. Jun, 2010 by Editor.

Practice size does not matter when dealing with compliance — even solo practitioners have to stay on the straight and narrow.

Even small dermatology practices have to stay compliant with government regulations — and although this sounds like a simple fact, it’s one that many Part B providers may overlook.

Ensuring physician practice compliance can be a complex path, and many practices think of it is something that large hospitals should focus on — after all, those are the entities that get all of the media exposure when they violate compliance rules. But every practice is responsible for compliance, no matter how big or small.

Doctors Take Note

In some cases, small practices think compliance rules don’t affect them — but also don’t realize they’re at risk of being noncompliant.

Example: “I met with a solo practitioner a few years ago

Continue Reading

Recovery Audit Contractors: Know These RAC Fast Facts

Posted on 24. May, 2010 by Editor.

RACs are just another tool in the government’s arsenal to collect improper payments.

You’ve got so many compliance acronyms flying at you every day that you may not be able to differentiate your RAC from the OIG. Know these quick facts about RACs to stay better informed.

• Recovery audit contractors (RACs) detect and correct past improper payments so CMS and the MACs can prevent such problems in the future
• RACs are hired as contractors by the government, and they can can collect “contingency fees,” which means that they get a percentage of the amount that they recover from providers who were paid inappropriately The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007

Continue Reading

Cost of Freezing Conversion Factor is Over $6 Billion — Just for 2010

Posted on 24. May, 2010 by Editor.

Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.

With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.

Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.

However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government…

Continue Reading

Compliance Red Flag: Update Your Modifier 59 and ‘Incident To’ Guidelines

Posted on 23. Apr, 2010 by Editor.

Keep signature, modifier 59, and ‘Incident To’ guidelines front and center.

If you’ve been worrying that the oncologist’s illegible signature on an order is going to come back to haunt your practice in an audit, CMS has offered
answers on when you’re in the clear and when that untidy scrawl could have reviewers requesting additional information.

1. Get Signature Guidelines Down Pat

Continue Reading

Gastro Coders: Be Aware of Medicare Screening Reqs Or Risk Payment Denial

Posted on 12. Apr, 2010 by Editor.

Following 10-year-rule eliminates G0121 rejection.

If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.

Use this guidance to capture every screening dollar your gastroenterologist deserves.

Home in on Eligibility Requirements for Average-Risk Test

Continue Reading

Use This Sample Appeal Letter As Ammo in Your Fight Against Modifier 25 Denials

Posted on 12. Mar, 2010 by Editor.

Attach your procedure notes and the OIG’s report to pack extra punch.

Even if you follow all of CMS’s rules in reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), your Medicare payer may sometimes still choose to deny your claim.

If you feel you deserve the pay for the EM service you performed, you should appeal the denial. Alice Kater, CPC, PCS, coder with Urology Associates of South Bend in Indiana, offers the following sample appeal letter (below) as an example of how she has challenged her payer to collect rightful reimbursement.

Continue Reading

OIG Hit List: Perfect Your 38220, 38221, and G0364 Usage

Posted on 22. Feb, 2010 by Editor.

Don’t sweat reporting 38220-59 if you meet these Medicare-approved conditions.

If your oncologist takes both a bone marrow biopsy and a bone marrow aspiration, whether you’ll see Medicare reimbursement depends on the two guidelines below. But watch out: With OIG scrutiny and a HCPCS twist, these guidelines will put your coding savvy to the test.

Append 59 for Different Sites and Encounters

Because a bone marrow biopsy and a bone marrow aspiration can provide different diagnostic information for certain leukemia evaluations, taking both specimens from the same patient on the same day isn’t unusual, according to R.M. Stainton Jr., MD, president of Doctor’s Anatomic Pathology in Jonesboro, Ark.

Snag: Medicare and some other payers use the Correct Coding Initiative (CCI) edits to restrict how you bill for “sequenced” surgical procedures through the same incision. For biopsy and aspiration, CCI bundles the following codes:

Continue Reading

Coding Compliance: OIG Targets Transforaminal Epidural Injections

Posted on 17. Feb, 2010 by Editor.

Verify that you’re counting injections and levels correctly to keep claims clean.

The Office of Inspector General (OIG) Work Plan for 2010 includes a closer look at Medicare payments for transforaminal epidural injections. The Work Plan specifically states, “We will review Medicare claims to determine the appropriateness of Medicare Part B payments for transforaminal epidural injections.”

Stay out of the OIG crosshairs by ensuring that your pain management specialist documents each procedure thoroughly. Follow these steps to count levels and assign the appropriate codes correctly.

1. Understand What ‘Transforaminal’ Means

Physicians often administer transforaminal epidurals laterally through the selected neuroforamen under fluoroscopy, says Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Mo. Once there, the physician performs an injection at the nerve root area to help relieve the patient’s pain. The medication goes into the anterior epidural space, “bathing” a specific spinal nerve as it exits the spinal cord.

CPT includes four codes to represent transforaminal epidural injections, which you choose between based on the injection site and number of injections:

Continue Reading