Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 20, 2005 PDF

CPO study may discourage you from billing for legitimate oversight

You’ve taken on the burden of providing an extra examination to every single one of your patients as they turn 65. And now the HHS Office Inspector General suspects you’re overpaid.

The “Welcome To Medicare” exam that started last January could award you with a higher payment for services you already provided to an existing patient in a previous examination, the OIG worries. The OIG plans to issue a report sometime in 2006 on the impact of the “WTM” exam on Medicare payments.

The OIG’s 2006 Work Plan also includes a lot of unfinished business from last year’s plan, including studies of your relationships with billing companies and Care Plan Oversight (CPO) for home health care. (See PBI, Vol. 5, No. 38.) In 2004, experts warned that the OIG could cause more scrutiny of technical violations of the assignment rules between physicians and billing companies, and that the CPO audit could discourage you from billing for legitimate oversight of home health.

Other issues held over from last year include: a study of Veterans Administration doctors improperly billing Medicare; excluded physicians improperly billing Medicare; relationships between pathologists and outside companies; whether physicians used the 26 modifier, for professional services, for interpreting cardiography and echocardiography tests; and “long distance” physician services , where sick patients travel miles to see a doctor.

The OIG abruptly dropped its plans to look into the use of the 25 modifier for E/M services on the same day as procedures, and also scrapped a planned report on the use of modifiers to override Correct Coding Initiative edits.

In other news:

• The House of Representatives failed to pass a budget package by Nov. 10 as planned, because it failed to muster enough Republican votes for steep Medicaid cuts. If the House budget bill passes by Thanksgiving, Washington observers expect a House-Senate conference in early December, after Congress returns from vacation.

The Senate bill includes a 1-percent increase for physician payments next year, but the House bill doesn’t address Medicare at all. The White House has discouraged legislators from dealing with Medicare, and conference negotiations may be difficult. If negotiators can’t reach an agreement, Congress could pass a continuing resolution to keep the government operating and work on the package into January and February, say Washington observers.

The worst-case scenario: lawmakers might give up hope for a reconciliation package and just pass the appropriations bills necessary for 2006. They could go back to the drawing board for the 2007 budget, leaving physicians still facing a 4.4-percent cut for 2006.