Gastroenterology Coding Alert

Focus on self-audits to eliminate possible problems before the feds come calling.

The OIG has some big plans next year for reviewing claims, and they span the whole spectrum of issues. Take a look at some of the areas under the OIG microscope so your practice can straighten out any issues before the auditors come knocking.

1. Potentially Inappropriate E/M Payments and ‘Identical Documentation.’ The OIG intends to go back in time -- all the way to 2010, to be exact, when reviewing E/M claims, according to the 2013 Work Plan, released on Oct. 2. "We will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations," the Work Plan states. The OIG also plans to review multiple E/M notes for each provider to determine whether electronic health record use by providers is allowing them to create cloned notes for different dates of service.

Bottom line: If a physician is documenting each patient identically rather than documenting based on the patient’s condition and medical necessity, that’s a red flag for the OIG.

2. Incident to services: The OIG intends to determine whether payment for incident-to services showed a higher error rate than non-incident to services. "Incident-to services are a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record," the Work Plan notes. "They may also be vulnerable to overutilization and expose Medicare beneficiaries to care that do not meet professional standards of quality."

Bottom line: Ensure that you have met all of the requirements for billing incident-to before coding that way. (Brush up on your incident-to coding with the article "4 Criteria You Must Meet Before Filing an Incident-to Claim" in Gastroenterology Coding Alert, Vol. 14, No.3.)

3. Payment for ‘G’ modifiers with ABN: The OIG intends to review Medicare payments for claims that included the "G" modifiers (GA, GZ, GX, GY) to indicate that a Medicare denial was expected. Often, these modifiers are used in tandem with an advance beneficiary notice (ABN). In the past, the OIG has found that Medicare inappropriately paid millions for services or supplies that should have been denied.

Bottom line: Ensure that you are correctly appending ‘G’ modifiers and that you utilize your ABN appropriately.

4. Use of Modifiers During Global Period. In many cases, practices are perfectly justified in adding a modifier to indicate that a patient is in the global period and that a service was unrelated and should be separately paid. Some practices, however, are abusing these modifiers, and the OIG wants to track them down. "Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments," the Work Plan notes.

Bottom line: Brush up on your global surgical modifiers and the appropriate use of these modifiers.

5. Errors in Place of Service Reporting. As there is a difference in payments for services provided by physicians in facility and non-facility settings, OIG intends to check on place of service codes used to claim physician services in outpatient departments and ambulatory surgical centers. "Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center," notes the Work Plan that indicates the need for this scrutiny.

Other issues: The OIG also plans to review claims for electrodiagnostic testing, ophthalmological services, personally-performed anesthesia, physical therapy, and sleep testing, among other topics. To review the complete list, read the Work Plan at https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.