Medicare Compliance & Reimbursement

Three out of four consults billed incorrectly, OIG says.

Consults look like a juicy target to fraud-busters in the wake of a new HHS Office of Inspector General report that found 75 percent of consults didn't meet Medicare requirements. Only one-third of the dollars providers billed in 2001--$1.1 billion out of $3.3 billion--were incorrect, but that's still a high price tag.

The OIG report reveals that:
 
· Providers billed nearly half of all consults (47 percent) as the wrong type of consult or at an incorrect level, accounting for $613 million in consult billings. In particular, providers upcoded 41 percent of consults and downcoded 5 percent, the OIG says. One-third of upcoded services were upcoded by two levels, and 10 percent were upcoded by three levels.

· One in five consults (19 percent) didn't meet Medicare's definition of a consult and providers should have billed them as a regular evaluation & management visit, adding up to $191 million in incorrect billings. Most of these visits "were actually lower-paying regular office or inpatient visits," the OIG says. Providers also tried to bill for a psychiatric diagnostic interview or a discharge management service as initial inpatient consultations. Also, nurses actually provided two of the consults, when nurses aren't eligible to bill for them.

· Nearly one in 10 consults (9 percent) didn't have enough documentation to justify billing a consult, and this cost Medicare $260 million. Reviewers found no documentation in the patient's medical record, including records from the consulting physician, the requesting physician and the facility.

· Providers coded almost all the highest-level consults (95 percent) incorrectly, the OIG says. On average, providers upcoded these by 1.9 levels, meaning almost all of these level five consults should have been level three instead.

Medicare should educate physicians about how to bill for consults, the OIG urges. This schooling should include when to bill the highest level of consultation.

The OIG especially had a problem with providers billing a follow-up inpatient consultation incorrectly. Providers should have billed some 94 percent of follow-up inpatient consults as a different service. The Centers for Medicare & Medicaid Services pointed out that Current Procedural Terminology 2006 already deleted the follow-up inpatient consultation and confirmatory consultation codes.