EM Coding Alert

The OIG will be.

Every year, the Office of the Inspector General (OIG) puts together a list, known as the Work Plan, of the hot spots it will focus on reviewing for the next year. For 2016, you’ll find two main targets in the E/M section, as well as in HIPAA and electronic health record (EHR) compliance.

By getting to know the targets, you can focus your efforts on ensuring your practice won’t be on the wrong side of the reviews. Read on to get the details on what you can expect from OIG this year.

Rarely Report Prolonged Services

One of the OIG’s 2016 intentions is to evaluate whether prolonged services were reasonable.

“They want to make sure that when providers are billing for these prolonged services, that the requirements are being met,” says Lynn M. Anderanin, CPC,CPC-I, CPPM, COSC, senior director of coding compliance and education for Healthcare Information Services in Park Ridge, Ill., in her audioconference “2016 Evaluation and Management Coding Updates” from The Coding Institute’s affiliate AudioEducator.com,

“The necessity of prolonged services are considered to be rare and unusual,” the OIG says in the Work Plan. Therefore, if you’re billing prolonged services (such as +99354 and 99355) for the majority of your E/M services, you’re definitely considered an outlier.

“So you should not have a provider that is always reporting prolonged services,” Anderanin warns.

The OIG news is particularly timely since CPT^® 2016 debuted two new codes (+99415-99416) for prolonged clinical staff services.

How to button up: You should only report prolonged service codes in addition to E/M codes that have a typical or specified time in the code descriptor. The +99354 descriptor indicates it’s for the first hour of prolonged services—the time involved does not have to be consecutive, but it does have to be on the same day. Use +99355 to report each additional 30 minutes beyond the first hour, depending on the place of service.

In addition, your documentation should clearly reflect an explanation of why the service was extended. “It should be documented why so much time was spent with the patient, and what actually was done at that time,” Anderanin says.

Bottom line: “The OIG is watching [these codes] pretty carefully, so you want to make sure that your documentation and your understanding of how to use the codes is correct,” says Donelle Holle, RN, practice administrator with Fort Wayne Pediatrics and President of Peds Coding, Inc., in her 2016 coding update audioconference from The Coding Institute’s affiliate AudioEducator.com.

Prove Medical Necessity For Home Visits

The OIG will also be checking whether your home visit services were reasonable and made in accordance with federal rules.

“Medicare has paid $559 million for these services since January 2013,” Anderanin says.

“Physicians are required to document the medical necessity of a home visit in lieu of an office or outpatient visit,” the OIG says in the Work Plan. CMS has disbursed $559 million in payment for these services since 2015, and the agency clearly wants to ensure that all of that is legitimate.

How to button up: If you’re reporting home visit codes 99341-99345 (for new patients) or 99347-99350 (for established patients), make sure you can document the medical necessity for the visit as well as a medical reason that the patient cannot make the trip to the office or clinic.

The medical necessity of the encounter (why the patient needs to see a doctor) is easy to document — it can be any type of problem that the physician would see a patient for in the office, such as influenza or a regular check for diabetes.

Documenting the medical reason that the patient needs treatment at home is more difficult. The patient does not have to be confined to the home (as is necessary for services provided under the home health benefit) but the medical record must document the medical need for the home visit made in lieu of an office or outpatient visit. If the patient is blind, a paraplegic, or meets other criteria that make it difficult for her to travel to your office, then you must document that accordingly. The reason for the home visit cannot be for convenience — for instance, if the patient can’t get a ride.

“There are very specific guidelines about when patients are receiving home nursing and home visits, and technically, they have to be home bound and should not be able to go out,” Anderanin explains. Home bound status could be defined differently by various payers, but, for home care as in nursing services, usually indicates that the patient cannot be away from home other than for medical issues for any period of time during the day. For the doctor to come to the patient’s home, the home bound status would then include the component that the patient cannot leave the home for even medical purposes.

Bonus: While you’re taking note of what is on the OIG 2016 Work Plan, you might also want to watch what is not on there. “One of the things that is not on the 2016 OIG Work Plan, which has been on for years, is the use of the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service),”Anderanin says. “That doesn’t mean it is going away or they are not looking at it; however, it is not listed on the plan for this year.”

Resource: To read the OIG’s FY 2016 Work Plan, go to http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf.