Orthopedic Coding Alert

On the OIG’s radar for 2016 are quality reporting and inpatient care.

On Nov. 2 last year, the HHS Office of Inspector General (OIG) published its Fiscal Year (FY) 2016 Work Plan. Some key areas where compliance is key turn out to be quality data, acute care, patient outcomes and safety, review of services and supplies, and ICD-10 implementation. Read on for what you can expect from OIG reviews in the coming year.

Hospital Quality Reporting Goes under the Microscope

The OIG has several new initiatives for hospitals in 2016. To begin with:

• OIG to inspect the CMS validation of hospital-submitted quality reporting data: The OIG will review hospital-submitted quality reporting data, to determine whether CMS has sufficiently validated the same. The quality data in question are those that CMS uses for the hospital value-based purchasing program and the hospital acquired condition reduction program. OIG will also look into the actions that CMS took post-validation.
• Check your Medicare payments during the MS-DRG window: OIG will scrutinize Medicare payments to acute care hospitals to determine whether certain outpatient claims billed to Medicare Part B for services provided during inpatient stays were allowable and in accordance with the inpatient prospective payment system. This is because prior audits have identified this area as at risk for noncompliance. “An example of site of service discrepancies that were identified in the past were performance of kyphoplasty as an outpatient despite an inpatient stay,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.
• OIG to count adverse events in post-acute care: OIG will look into the national counts on adverse and temporary harm events for Medicare benefi­ciaries receiving post-acute care in inpatient rehabilitation facilities (IRFs) and long-term care hospitals (LTCHs). IRFs provide 11 percent of post-acute facility care and accounted for $7 billion in Medicare expenditures in 2011. LTCHs are the third most common type of post-acute care facility; the OIG is concerned that adverse events in these settings are having a negative impact on a significant number of patients and costing serious dollars. The OIG anticipates determining the extent to which these events are preventable and will provide key factors causing the events.

Way to go: Proactively collect data on patient care outcomes and safety events in your hospital and identify performance trends. LTCHs will want to implement any changes proposed in these reports in the years to come to avoid preventable harm.

You could follow the already existing Joint Commission’s safety standards which require that at least every 18 months, the hospital should select one high risk process and conduct a proactive risk assessment.

Ventilators Become a ‘Prime Target’

The OIG also will launch a new investigation into billing trends for ventilators, respiratory assist devices (RAD), and continuous positive airway pressure (CPAP) devices from 2011 to 2014. This stems from a significant increase in billing for ventilators, especially for pressure support ventilators.

Anticipate Scrutiny of 340B Program

Although not a new effort, the OIG is looking into prescription drugs under the 340B program, to find ways to cut on Medicare costs through 340B discounts.

The issue: As of now, eligible healthcare providers can purchase prescription drugs at discounted prices under the 340B program. Then these providers bill Medicare and other insurers for the full price of the drug, piling on the drug cost to payers unreasonably.

Additionally, the OIG will now move the dial on inappropriate drug pairs under Medicare Part D. These are drugs that should not be prescribed along with other drugs due to the possibility of drug interactions and undesirable side effects.

Prepare for a Variety of New Provider Inquiries

The OIG wants to determine whether CMS made payments correctly for services, supplies, and DME, specifically reviewing whether those physicians and NPPs are in fact Medicare-enrolled and legally eligible to refer/order.

So, brace yourself for new reviews of Medicare services, supplies, and DME that physicians and non-physician practitioners (NPPs) refer or order for patients.

Pay attention: OIG will also review Medicare Part B claims for anesthesia services to find out whether the claims were valid and the beneficiary had a related Medicare service. Likewise, the OIG will be examining the adequacy of Medicare payments to physicians for evaluation and management (E/M) home visits and prolonged E/M services.

“There are not typical services provided by neurosurgeons and therefore this should have limited impact on most practices,” Przybylski says.

Show OIG Your ICD-10 Success

The Work Plan includes taking stock of CMS’s management of ICD-10 implementation as well. The OIG may review CMS’s and its contractors’ assistance and guidance to hospitals and physicians, as well as assess how the ICD-10 transition is affecting claims processing, including claims resubmissions, appeals, and medical reviews. This looks like OIG is trying to take stock of the situation post ICD-10.

“Remember that through September, CMS is only looking for accuracy of the ICD-10 family (the three alphanumeric characters before the period).  Subsequently, CMS is currently expecting accuracy of the entire code itself,” Przybylski says.

“I think the OIG wants to look at the overall process and then determine if there are any problem areas,” contemplates Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA.

Final takeaway: The OIG’s Work Plan gives you a good idea of targeted areas to devise your 2016 strategy. The OIG is continuously investigating in multiple ways, such as analyzing your Medicare and Medicaid payment data amongst other things. So, be careful about not just fraud and abuse, but also waste that could be prevented. Be proactive and remember that waste might easily become overpayments and could snowball into potential False Claims Act and Stark Law violations.

“Unfortunately, healthcare providers do not have unlimited resources when it comes to addressing all potential compliance issues,” reflects Abbey. Therefore, “hospitals and other healthcare providers need to prioritize these OIG identified issues along with other compliance issues facing the given healthcare provider.”

Link: To view the entire FY 2016 OIG Work Plan, go to http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf.