This month’s article was provided by The Coker Group, an SMA approved partner.

• Using the OIG Work Plan to Improve Billing

  By Crystal Reeves, CPC, CMPE

  Most managers would probably agree that one of the most difficult aspects of practice management is keeping abreast of changing payer rules and (often confusing) billing guidelines. In fact, striving to keep current on what is and is not appropriate billing for dozens of services for dozens of payers is a lot like the circus performer who is trying to keep several china plates spinning on bamboo sticks. It takes skill, focus and determination. Unfortunately, when we fail, the consequences can be much more severe than a broken platter.

  One way practices can help prevent missteps in billing is to review the Office of Inspector General’s (OIG) Work Plan each year. The annual work plan outlines the billing areas that the OIG has found to be most problematic and will therefore be focusing its attention on in the coming year. This work plan can help managers identify areas that may need attention within their own practices.

  While the entire plan for 2008 can be reviewed on the OIG’s website given below, the following focus areas from the Medicare Physicians and Other Health Professionals and Medicare Part B Drug Reimbursement sections are particularly noteworthy.

  Medical Necessity: References to medical necessity appeared in almost all of the OIG’s target areas. In Medicare’s words, medical necessity continues to be the “overarching criterion” when it considers appropriateness of services. The OIG has identified areas where costs have risen dramatically in recent years and will monitor those services to insure that all services are medically necessary as defined by Medicare. Areas of focus include:

  Psychiatric services
  The OIG will determine whether claims submitted for psychiatric services were supported by medical necessity and billed according to Medicare guidelines.

  Coker’s Recommendation: Insure that the supporting diagnosis code is submitted on all claims and that the documentation also supports the diagnosis and the service billed. Since many CPT codes used by psychiatrists are “time-based codes”, the documentation needs to show the amount of time spent with the patient.

  “Incident to” services
  “Incident to” services continue to pose challenges for practices, and have appeared on the OIG work plans in previous years. The study will review the medical necessity for those services billed “incident to” a physician’s service and plan of care as well as the documentation of those services. Medicare’s Claim Processing Manual Section 30.6.4 addresses “incident to” guidelines.

  Coker’s Recommendations: It is important to note that under the ‘incident to” guidelines, the physician must be available in the office suite when an employee is billing “incident to” services. The question often arises regarding the documentation requirements for the visit 99211 which is subject to the “incident to” guidelines. While the CMS Documentation Guidelines do not specifically address 99211, many carriers have established their own requirements. We recommend checking with your local carrier for documentation requirements for 99211.

  Polysomnography
  The OIG reports that payments for sleep studies have increased from $62 million in 2001 to $170 million in 2004. As a result, it will be reviewing the medical necessity of these studies. Medicare covers sleep studies for a limited number of diagnoses that can be found in your Local Coverage Determination.

  Coker’s Recommendation: Check your Local Coverage Determination (LCD) to review the supporting diagnoses. As a caution, ensure that the medical record accurately supports the diagnosis entered on the claim. If the diagnosis does not support medical necessity, be sure to obtain a signed Advance Beneficiary Notice from your patient so that you may bill the patient

  Interventional pain management procedures
  Medicare paid nearly $2 billion for these services in 2005. The OIG will review payments for these procedures and determine the appropriateness of the services. These services will also be reviewed for medical necessity.

  Coker’s Recommendation: The documentation should show that the patient has not responded to other treatment. We recommend that practices obtain assigned Advance Beneficiary Notice from the patient before rendering these services.

  Two other areas under OIG review for medical necessity include: high frequency chiropractic treatments and high utilization of ultrasound services.

  Coker’s Recommendation: Review the CPT directives for using codes 98940-98943 for spinal manipulation and ensure that the documentation supports the number of spinal areas billed for. For ultrasound services, we recommend that practices review their Local Coverage Determinations for the ultrasound service provided and ensure that the medical necessity is documented in the record.

  Other areas of focus for the 2008 work plan include:

  Place of Service Errors
  Since Medicare reimburses physicians at a higher rate for services performed in their offices than it does for services that are performed in a hospital or ASC, it is extremely important to enter the appropriate place of service code when entering charges.

  Coker’s Recommendation: How can you catch mistakes? For those services performed in a hospital or ASC we recommend generating reports based on place of service to verify posting accuracy.

  Evaluation and management services during global surgery periods.
  The Center for Medicare and Medicaid Services (CMS) has established global periods for all procedures. CMS’s Medicare claims Processing Manual Chapter 12, Section 40 contains the criteria for the global surgery package. The OIG will determine if the number of E/M services during the global period has changed since the global concept was introduced.

  Coker’s Recommendation: This is an area that continues to be the cause of billing errors. If a practice is uncertain as to how long the global period is for a procedure, the information is available on the CMS website under the physician fee lookup tool.
  
  The global period typically includes the day before surgery (for 90 day global procedures), the day of surgery and the specified number of days following surgery. If the physician does not perform all of this work, the appropriate modifier should be appended. It is not appropriate to have another physician in the group perform pre-surgery or follow up care and bill a separate E/M service.

  Payment for chemotherapy drug administration services.
  OIG studies showed that payments for chemotherapy drug administration services increased 217% between 2003 and 2004, and yet the chemotherapy drug costs increased only 4%. Therefore, the OIG will be reviewing chemotherapy administration charges for appropriate billing.

  Coker’s Recommendation: While part of this discrepancy is no doubt due to more practices “brown bagging” the chemotherapy drugs along with the change in the Medicare method of reimbursement for drugs, there is also the possibility that some practices are using the chemo administration codes for non-chemotherapy administration. Practices can take prevention measures by reviewing the claims to confirm that the chemo administration codes are used only with chemo drugs.

  These issues represent only a fraction of areas that the OIG will be reviewing in 2008. The entire OIG 2008 Work Plan can be reviewed at: http://oig.hhs.gov/publications/docs/workplan/2008/Work_Plan_FY_2008.pdf. In addition to reviewing the plan for other areas that might be pertinent to your practice and services you offer, be sure to subscribe to your Medicare Carrier’s e-newsletters for helpful information on billing and coding policies.

  For additional assistance on billing, coding, and documentation review, you may email Crystal Reeves at creeves@cokergroup.com.