Get a Jump on 2013 Government Reviews

By Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P

Use this year’s OIG Work Plan to control risk and keep physician compliance programs healthy.

When preparing to close out one calendar year and move to the next, it’s important to review your Medicare compliance efforts. A comprehensive auditing and monitoring program is crucial to yearly compliance planning. Developing a program includes identifying specific items that have been problematic for your medical practice or facility throughout the year. You can derive this information through auditing, by knowing general risk areas for your practice or facility, and from reviewing items discussed in the Office of Inspector General’s (OIG) Work Plan for Fiscal Year 2013 (Work Plan).

Anesthesia and Pain Management CANPC

The OIG’s annual Work Plan lists specific areas of interest the government intends to investigate throughout the year. Having this information enables health care organizations to identify and correct potential compliance risks before they become a liability.

We’ll begin by examining Part 1: Medicare Part A and Part B as it pertains to the physician practice. Next month, we’ll take another look at this section, focusing on the items that pertain to hospitals.

Part 1: Part B

Many items affecting physician practices are found in the “Other Providers and Suppliers” portion of the Medicare Part A and Part B section. Only a few of these items are directed specifically at physicians, but you’ll want to broaden your focus to include those items that look at Part B services in general.

Assignment Rules and Excessive

“Noncompliance with Assignment Rules and Excessive Billing of Beneficiaries” is not a new item in the Work Plan, but it is important to review.

Start by reviewing your systems, and verifying that you have everything in place to write off appropriate amounts reflective of current Medicare fee schedule rates. Also make sure you are using Advanced Beneficiary Notices (ABNs) when appropriate, and have a solid process in place to use that important tool. For example, ensure you have a system for reviewing medical necessity for procedures and ancillary services performed in your office. This will give beneficiaries the opportunity to make an informed consumer decision about the services they’re about to or will soon receive. It also helps to ensure your practice will be appropriately paid for services rendered.

Place of Service

“Place-of-service Coding Errors” is another familiar item in the Work Plan, reinforcing the need for physician practices to review their place-of-service (POS) coding. The OIG will be looking specifically for services performed in an ambulatory surgery center (ASC) or a hospital outpatient department. In those settings, applying the incorrect POS code may result in an improper higher payment. You’ll want to pay special attention to your POS coding for hospital outpatient-based clinics, hospital outpatient surgeries, and ASC services; your POS code should match the actual place where the services were performed. For example, if your physician is providing services at a facility-based (provider-based) clinic, the POS code is 22 Outpatient hospital, not 11 Physician office. Although this may be the physicians’ main office location in some instances, this is still an outpatient hospital location and must be reported as such.

Anesthesia Services

Anesthesiology practices have a new item to examine specifically aimed at services coded with modifier AA Anesthesia services performed personally by anesthesiologist, or when an anesthesiologist assists a physician in the care of a single patient. The OIG will examine anesthesia services to determine whether they were personally performed and billed appropriately with modifier AA appended. Payment for medically directed anesthesia services billable with modifier QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals is 50 percent of the amount allowable for services reported with modifier AA.

Review your documentation and determine if it establishes that the anesthesiologist personally performed the services. If services were only directed by the anesthesiologist, and not personally performed, modifier AA would not be appropriate.

Ophthalmological Services

Ophthalmology practices have a new item to consider: The OIG is reviewing “questionable billing” in 2011 for ophthalmology services. The review includes analysis of specific geographic locations where providers have been problematic; although, at this time additional details have not been provided on location. There appears to have been an increase in the expenditure in Medicare dollars in ophthalmology and concern about potential fraud in the recent past; however, few details are provided on exactly how much. If the OIG finds issues with 2011 documentation, they will move forward into other documentation for providers with problematic records.

Due to the generic nature of this review, use it as an opportunity to take an overall look at your documentation. What are you doing well? Where are your risks? Review your use of incident-to guidelines regarding technologists in your office because this is always a concern under OIG review. Any areas that have been problematic for your practice in previous audits could be reviewed to verify the issues have been resolved.

Electrodiagnostic Testing

Several types of specialists perform various types of electrodiagnostic testing in their offices. The OIG has a new item in its Work Plan this year regarding inappropriate use of these tests. They will be reviewing questionable billing and looking at Medicare utilization rates by provider specialty, diagnosis, and geographic area for these services. There is concern specifically about using this testing for financial gain.

This gives providers who perform in-office electrodiagnostic testing an opportunity to review their records and determine how often these services are being performed. Are there any obvious patterns that could appear suspicious? Is there solid medical necessity on file for all patients who had testing? Is there documentation to support all testing performed? This could be a serious issue for practices, so detailed records will be vital.

Claims with G Modifiers

The OIG will be reviewing possible errors in instances when providers expected denials.

When a provider obtains an ABN, modifier GA Waiver of liability statement issued as required by payer policy or modifier GX Notice of liability issued, voluntary under payer policy (depending on whether the ABN was required or voluntary) is appended to the procedure code. In other instances, payments are not expected, and modifiers 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 or GZ Item or service is expected to be denied as not reasonable and necessary is used. In those instances, the OIG has concerns contractors have made payments inappropriately. A previous review showed that $4 million in inappropriate payments were made on claims with modifiers GA and GZ appended.

Review services billed from your practice with those four modifiers. Have payments been made by the contractor? If so, was the payment refunded to the contractor? Were the modifiers applied appropriately originally? This is an important review item giving providers the opportunity to analyze modifier application processes, as well as refund processes.

These are only a few of the important items from this year’s Work Plan. It’s advisable to review the entire document. The Medicaid section is important to all providers who see Medicaid patients. The Public Health section includes reviews of research grant-related topics for providers who perform grant-funded research. There is great information throughout the Work Plan that can be used to help all health care entities control risk and maintain compliance.


Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, serves as a clinical technical editor for OptumInsight, and has nearly 20 years of experience in the health care industry. She is a former chief compliance officer and chief privacy official. She teaches CPT® coding as an approved AAPC instructor, and is a former member of AAPC’s ICD-10 curriculum development team. She holds a bachelor’s degree in health care administration from the State University of New York – Empire State College and a master’s degree in health systems administration from the Rochester Institute of Technology (RIT).


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