Part B Insider (Multispecialty) Coding Alert

Published on Mon Oct 06, 2003 PDF

The HHS Office of Inspector General may have an ambitious agenda for overlooking physician claims in the future, but the OIG's latest findings on physician claims are pretty encouraging.
 
In a new report on National Correct Coding Initiative edits (OEI-03-02-00770), the OIG found that the NCCI Edits are mostly very successful. Medicare paid appropriately for 98 percent of services targeted by NCCI edits in 2001. And of the remaining 2 percent, an overwhelming 70 percent may have been paid correctly as well because of adjustments when two services bundled by the NCCI were paid on two different days.
 
Meanwhile, the OIG audited Part B carrier Trailblazer Health Services' error rate for the first and third quarters of 2002 and found that Trailblazer improperly paid $93,863 in the first quarter and $35,474 in the fourth quarter. These pittances resulted from some "improper claims" and procedural weaknesses, the OIG states. Also, Trailblazer reported incorrect information to the Centers for Medicare & Medicaid Services in several areas, the OIG claims.
 
These findings are great news for Trailblazer, but not necessarily for physicians, says attorney David Glaser at Fredrickson & Byron in Minneapolis. They may mean that Trailblazer is being too strict. "If you get audited by a Medicare carrier, the odds are they inaccurately applied at least one rule when they did it," Glaser says. For example, carriers are supposed to apply both the 1995 and 1997 evaluation and management coding guidelines to E/M claims, but they often apply only one of those.
 
The carriers are still finding overpayments in physician claims, but probably not as many as in the peak years, Glaser adds.
 

 A 7-year-old entry in a dialysis patient's medical chart has saddled a highly regarded nephrologist with a $100,000 restitution order.
 
In addition to the restitution, William Couser must serve five years' probation and 1,000 hours of community service. The sentence comes on the heels of Couser's March 26 guilty plea to a single count of making a false entry on a patient's chart.
 
According to U.S. Attorney John McKay, Couser indicated that he was present during the patient's dialysis treatment - a requirement when billing for a physician's professional services relating to dialysis - when in fact he wasn't there. Specifically, Couser wrote, "Dialysis in progress. No acute problems. Patient seen and examined."
 
As part of the plea agreement, Couser - a professor at the University of Washington's School of Medicine - admitted to writing similarly fraudulent notes for other patients between 1991 and 2002.