2008 OIG Plan

Put Away Your Crystal Ball and Take a Look at the Future.

By Rhonda Buckholz, CPC

The Office of Inspector General (OIG) recently released its work plan for 2008, allowing us to understand issues under investigation, giving us information to ensure we are providing services correctly, and helping us prepare for future regulations.

Evaluation and Management – CEMC

Place of Service Errors: Many places of service pay higher when done in physician offices. The OIG will check to see that the services were really provided where listed on claims.

Tip: Always check your claim submissions to ensure that you have the proper place of service indicated on your CMS 1500.

E/M During Global Surgery Periods: The 2008 work plan says,

“We will review industry practices related to the number of evaluation and management (E/M) services provided by physicians and reimbursed as part of the global surgery fee. CMS’s Medicare Claims Processing Manual, Chapter 12, section 40, contains the criteria for the global surgery policy. Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure and related E/M services provided during the global surgery period. The global surgery fee includes payment for a certain number of E/M services provided during the global surgery period. We will determine whether industry practices related to the number of E/M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.”

Tip: Make sure you understand when it is appropriate to bill for additional visits during postoperative periods, and watch use of modifier 24.

Medicare Payments for Selected Physician Services: OIG will focus on Medicare Part B payments for selected physician services, reviewing appropriateness of Medicare payments for various types of physician services and determining if services were paid in accordance with Medicare. Section 1861(q) of the Social Security Act (SSA) describes physician services as professional services performed by physicians, including surgery, consultation and home, office, and institutional calls.

Incident To Services: The OIG will examine Medicare services selected physicians bill incident to their professional services, and the qualifications and appropriateness of the non-physician staff performing them, reviewing medical necessity, documentation and quality of care.

Tip: Incident to services can be tricky and rules do change. Make sure your practice is up on the regulations regarding these services. Your state’s medical society is always a good resource for understanding these regulations.

Appropriateness of Medicare Payments for Polysomnography: The OIG will investigate the appropriateness of payments for polysomnography services. These services, which typically occur at a specialized sleep clinic or center, is a diagnostic test in which a number of the patient’s physical parameters such as heart rate and brain activity are measured during sleep. Section 1862(a)(1)(A) of the SSA provides that Medicare will pay for services only if they are medically necessary. Sleep studies are reimbursable for patients with symptoms consistent with sleep apnea, narcolepsy, impotence (the diagnosis of which can benefit from polysomnography), or parasomnia in accordance with the Medicare Benefit Policy Manual, Pub. No. 100-02, Chapter 15, section 70. Medicare payments for polysomnography increased from $62 million in 2001 to $170 million in 2004.

Tip: Make sure your office has current copies of Local Coverage Determinations (LCDs) to determine you have the latest information regarding medical necessity guidelines.

Assignment Rules by Medicare Providers: This review will identify if Medicare providers are adhering to assignment rules in billing Medicare beneficiaries.

Section 1866(2)(A) of the SSA disallows participating physicians/suppliers from charging Medicare beneficiaries more than the deductible and coinsurance based upon the approved Medicare payment amount determination. Providers who accept assignment must accept Medicare’s payment and beneficiary copayment, referred to as the Medicare allowed amount, as payment in full for all covered services. Providers cannot “balance bill” beneficiaries for amounts in excess of the Medicare allowed amounts.

Medicare Payments for Interventional Pain Management Procedures: The OIG will determine the appropriateness of Medicare payments for interventional pain management procedures. They consist of minimally invasive procedures such as needle placement of drugs in targeted areas, ablation of nerves, and some surgical techniques. Many clinicians believe these procedures are useful in diagnosing and treating chronic, localized pain not responding well to other treatments. Interventional pain management is a new and growing specialty. In 2005, Medicare paid nearly $2 billion for these procedures.

Tip: This is a growing field. Make sure you know guidelines and regulations prior to offering these types of services.

It is always a good idea to read the plan in its entirety to see how the upcoming reviews might affect your practice.


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