Part B Insider (Multispecialty) Coding Alert

Published on Fri May 23, 2003 PDF

You may be hearing frequently from carriers about some codes you bill often, but it could be the HHS Office of Inspector General pulling the carriers' strings.

"Medicare and the OIG drive what the hot buttons are," says consultant Garnet Dunston, CPC, MPC, president and CEO of Dunston Enterprises in Bouse, Ariz. The OIG's Work Plan and other documents provide a blueprint for carrier audits.

For example, one client of Spring Lake, N.J.-based HealthCare Resource Management Inc. is facing heavy carrier scrutiny of its billings for bone density screening. That just happens to be one of the areas OIG pinpointed in its latest Work Plan, says HRM President Catherine Brink, CMM, CPC.

The items in the Work Plan tend to be things that "cost Medicare a lot of money the year before," Brink says. They'll see spikes in the billing and go back and look into them.

Besides bone density screenings, the OIG fiscal year 2003 Work Plan pinpointed the following areas of concern for physicians:

Physician consultation services

Whether carriers properly apply Correct Coding Initiative edits

Coding of high-level evaluation and management services

Billing for physician evaluation of dialysis
 

"Long-distance" claims, when the patient traveled to see the physician

Arrangements between physicians and ambulatory surgery centers

Physicians billing incident-to for services provided by allied professionals

Emergency room physicians reassigning their benefits to staffing companies

Payments to nonphysician practitioners who may be billing outside their scope of practice.

The focus on billings for high-level E/M services could cause problems for physicians as well, Brink notes. If you're billing for level-four visits regularly for both new and established patients, you could be writing a ticket to Auditville.

Just because a service isn't on the OIG hit list doesn't mean it won't get audited if you bill heavily for it.

"Doctors that vary from the national norm specifically are the ones that get audited," insists consultant Jim Collins with Compliant MD in Matthews, N.C. So you can "see behind the scenes what the auditors are looking at" if you compare your own code use to national statistics.

"Providers get together, and they talk: 'I'm getting paid for this, I'm getting paid for that,'" Dunston says. But getting paid for a code regularly and keeping the money are two different things. If the carriers decided you're overbilling a particular code without the documentation to back it up, you'll pay back fines as well as the reimbursement you gained.

If you're higher than the average for your specialty, that doesn't necessarily mean anything, Collins says. There are general cardiologists who don't do any procedures, and cardiologists who insert five different catheters into patients and electronically ablate different tissues. The latter "would stick out from the norm, but the medical record would support it," Collins says.