Gear Up for 2009 OIG Work Plan
The best way to advance is to avoid the hard hits.
By Jillian Harrington, MHA, CPC, CPC-I, CCS-P
In October 2008, the Department of Health and Human Services Office of Inspector General (OIG) published its annual Work Plan. In it are the activities each office within the OIG will undertake for the upcoming federal fiscal year.
As usual, some items were added to the plan, some items were removed, and some items remain ongoing. By examining this plan, you get a sense of what the federal government feels are areas of concern in the provider sector. This information is helpful for creating your own compliance work plan, or updating an existing one. For 2009, the OIG has added several new items of interest to its plan that you should be aware of.
Medicare Practice Expense
As part of the calculation of the Medicare Physician Fee Schedule (MPFS), the Centers for Medicare & Medicaid Services (CMS) accounts for estimated practice expense (such as rent, wages, and equipment). In 2009, the OIG will take a look at actual practice expense in certain specialties to determine if their estimates are comparable to the practice’s actual cost. Although this is not a review specifically of physician coding, billing, or documentation, it is a good opportunity to see your own practice expense. Are all of your expenditures above board? Are you paying fair market value for your office space and equipment rentals? Be sure to accurately report your actual practice expense to the OIG in case someone comes knocking on your door.
Colonoscopy Service Payments
The 2009 plan takes a general look at payments to physicians for colonoscopy services. The OIG will “determine whether Medicare payments for colonoscopy services were properly supported, billed, and paid in accordance with Medicare requirements.” Documentation of medical necessity and the appropriate billing of screening colonoscopy are important to colonoscopy payment. Examine your colonoscopy billing practices to be sure you meet Medicare’s specific requirements for these services.
There are limited circumstances when services are billed to the Medicare program under a physician’s identifier when the services are provided by another practitioner. These instances, typically known as “incident-to” services, have been an audit favorite of the OIG and CMS for several years. This year is no exception, with an item specifically targeted at non-physician practitioners’ qualifications, and whether these qualifications meet the standard of care recognized in the industry for incident-to service. As always, you should fully understand the incident-to billing guidelines and make certain your non-physician practitioners are working within their scope of practice in your state.
In general, most evaluation and management (E/M) services require a provider either examine the patient in person or visualize some aspect of the patient’s condition without involving the judgment of a third party. A previous review by the OIG found there were instances of inappropriate physician services billing for skilled nursing facility or home health agency patients when there wasn’t a face-to-face visit—only contact via telephone between the patient and the provider. In 2009, the OIG will be reviewing long-distance patient visits to determine if an actual face-to-face visit was performed by the physician. If your practice regularly sees patients with a permanent address elsewhere (for example, retirees from the North who spend winters in Arizona or Florida), prepare for inclusion in this review. Strong documentation of your E/M services is important. If you provide any services partially conducted via telephone, such as care management or other similar items, be sure the documentation for those services is clear and concise, and supports any and all services where charges are made.
Unlisted Procedure Codes
Occasionally, providers perform procedures, typically surgical in nature, that don’t have a procedure code. This OIG review will look at procedures billed with unlisted procedure codes, examining the overall usage of these codes. Unlisted codes are individually reviewed by Medicare contractors and are manually priced. If your practice bills unlisted procedure codes on a regular basis, review these claims. Can these unlisted procedures be described better with an existing procedure code and the addition of modifier 22 Increased Procedural Services? Either way, you should provide highly detailed documentation for the service to support the use of an unlisted procedure code or the increased services modifier.
For services that are statutorily excluded from the Medicare program or otherwise do not meet the definition of a covered service, you should use modifier GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit. Examples of when to use modifier GY include services such as cosmetic surgery, alternative therapies, dental care, and others. Currently, there isn’t a requirement for providers to notify the patient of their potential payment responsibility for these services in advance, which is much different than requirements under Advanced Beneficiary Notice
(ABN) guidelines. (See the info box “Learn more about ABNs.”)
For statutory exclusions, notice to the patient isn’t required nor is a cost estimate. In 2006, 53 million claims of this nature were submitted to the Medicare program in excess of $400 million. The OIG says it has concerns about patients unknowingly incurring large expenses that they will be responsible for paying on their own. Therefore, the OIG will review patterns and trends of provider use of the modifier GY.
Do not use modifier GY when an ABN is on file—use modifier GA Waiver of liability statement on file instead. Use modifier GZ Item or service expected to be denied as not reasonable or necessary when there isn’t an ABN on file and you expect the claim will be denied and deemed not reasonable or necessary. The only time you should use a GY modifier is when there is a statutory exclusion or it is not a Medicare offered benefit. Be sure you are using it at the proper time.
There are many items in this year’s OIG Work Plan that continue from previous years’ work plans. Some of these items include:
- Place of service (POS) errors
- E/M Services during global surgery periods
- Services performed by clinical social workers
- Appropriateness of Medicare payment for polysomnography
- Physician reassignment of benefits
- Patterns related to high utilization of ultrasound services
- Medicare payments for chiropractic services billed with the Acute Treatment (AT) modifier
Avoid OIG Scrutiny
If you accept funds from the federal government (Medicare, Medicaid, etc.), you can expect some degree of interaction with these watchdog government agencies. Their role is to protect the Medicare trust fund to assure there is funding available for future generations. Not all interaction with the OIG or other benefit integrity groups has to be negative or frightening. If you are doing a good job in your practice from a compliance perspective, you should not fear these agencies.
Two steps to help you avoid government agency scrutiny are:
- Have an active compliance program in your practice. A written program on a shelf won’t suffice. A living, breathing compliance program will protect your providers and yourselves, and hopefully mitigate potential negative effects of these reviews.
- Make sure you include the items the government agencies and private payers are concerned about in your auditing and monitoring work plan for the year. Analyzing the work plan and determining potential risk areas for your practice will enable you to design an effective compliance auditing and monitoring plan.
There is more to come on 2009 OIG Work Plan. Next month, we’ll look at what the OIG has in store for hospitals.
Learn more about ABNs: ABNs are typically used for services not considered “reasonable and necessary” under the Medicare program. The service is sometimes covered, but not in a particular instance due to the diagnosis, the number of times the service is provided, or another similar reason. In these instances, providers must notify patients in advance of their responsibility and, effective March 1, 2009, give the patient an estimated cost up front.
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- acute treament
- clinical social workers
- compliance program
- evaluation and management
- Inspector General
- Medicare Physician Fee Schedule
- Medicare Practice Expense
- Modifier GA
- modifier GY
- non-physician services
- OIG Work Plan
- place of service
- reassignment of benefits
- service payments
- statutory exclusions
- ultrasound service
- unlisted codes
- work plan
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