The annual Office of Inspector General (OIG) Work Plan
is a goldmine of information pertaining to provider compliance challenges. Unfortunately, most practices are completely unaware of this document and the valuable information it includes, says Amy Bailey CHC, CPC, COC (CPC-H), CPC-I, CCS-P,
principal of HBE Advisors LLC. Bailey, who helps practices maintain compliance through auditing and recommended corrective action plans, says the OIG Work Plan
can serve as the basis for a practice’s overall compliance plan.
The OIG 2015 Work Plan
was released on October 31, 2014. In it, the OIG raises compliance issues related to chiropractors, radiologists, ophthalmologists, physical therapists, and more. Bailey reviews some of the highlights that pertain to physician practices, including insight into what specific issues the OIG may be targeting
. Anesthesia services—payments for personally performed services What the Work Plan says: The OIG will review claims with an AA modifier (used to denote anesthesia services personally performed by an anesthesiologist) to determine whether this modifier is appropriate. Modifier QK, which indicates that an anesthesiologist did not perform these services, limits payment to 50% of the Medicare-allowed amount.
How to maintain compliance: Practices need to append each modifier correctly, depending on who administers the anesthesia, says Bailey. This issue mostly pertains to anesthesiologists rendering general anesthesia in a hospital setting. Office-based anesthesia is more likely a sedation type of service that is coded and billed differently, she adds.
Chiropractic services—Part B payments for noncovered services What the Work Plan says: The OIG will take a closer look at unallowable Medicare payments for chiropractic services, including Part B payments for manual manipulation of the spine to correct a subluxation when the patient has a neuro-musculoskeletal condition for which manipulation is appropriate treatment. Maintenance therapy is not medically reasonable or necessary.
How to maintain compliance: Some practices simply use a covered diagnosis code that isn’t justified by the documentation. This can definitely raise a red flag to auditors, says Bailey. Medical record documentation—including the ICD-9 diagnosis code used for billing—must accurately reflect the patient’s condition, she adds. If the patient receives treatment for ongoing chronic pain, physicians shouldn’t expect Medicare payment.
Chiropractic services—Questionable billing What the Work Plan says: The OIG will identify inappropriate payments in light of a recent audit that identified a chiropractor with a 93% claim error rate and inappropriate Medicare payments of approximately $700,000.
How to maintain compliance: As mentioned previously, documentation must clearly reflect the true reason why the patient receives treatment. If the treatment is performed for a non-covered diagnosis, the chiropractor may be able to bill the patient directly.
Diagnostic radiology—Medical necessity of high-cost tests What the Work Plan says: The OIG will determine whether these tests were medically necessary and whether the use of such tests has increased over time.
How to maintain compliance: High-cost radiology tests include advanced imaging services such as CTs and MRIs. The compliance issue is that some referring physicians order these tests without having a medically legitimate reason to do so. Bailey says radiology centers should take the time to verify the diagnosis on the physician order to ensure that it’s correct and as specific as possible. Ideally, the order should reflect a medically necessary diagnosis. If the diagnosis is non-covered, the center may be able to bill the patient directly.
Imaging services—Payments for practice expenses What the Work Plan says: The OIG will review Part B payments to determine whether the practice expense component of these payments is appropriate. These expenses include office rent, wages, and the cost of maintaining and using equipment.
How to maintain compliance: The OIG is likely trying to understand whether its payment for the fixed components of the service are accurate, says Bailey. However, this issue may pertain to physicians who inappropriately submit claims for both a professional interpretation as well as the technical component that includes overhead. For example, this could occur when physicians interpret images in the hospital setting. When this is the case, physicians aren’t entitled to payment for the technical component. Instead, physicians should report modifier -26 when performing the professional interpretation only.
Selected independent clinical laboratory billing requirements: What the Work Plan says: The OIG will identify labs that routinely submit improper claims and recommend recovery of overpayments.
How to maintain compliance: Bailey says clinical labs should be on the lookout for these compliance traps:
- Furnishing lab services without a physician order
- Submitting claims with a payable diagnosis that’s not supported by documentation
- Billing a code for a comprehensive lab panel when the lab doesn’t perform all of the tests within that panel
- Billing for analyses of hospital specimens (Note: The hospital should bill for this. Labs receive compensation via a contractual agreement with the facility.)
Ophthalmologists—Inappropriate and questionable billing What the Work Plan says: The OIG will determine the locations and specialties of providers with questionable billing practices.
How to maintain compliance: As with many issues in the Work Plan, medical necessity may be a driver, says Bailey. The OIG may look for widespread patterns of non-compliance in certain states or regions. Accurate and thorough documentation is important.
Physicians—Place-of-service coding errors: What the Work Plan says: The OIG will review Part B claims for services performed in ambulatory surgery centers and hospital outpatient departments to determine whether the place-of-service code is correct. Physicians receive higher reimbursement when a service is performed in a non-facility setting, including the practice setting.
How to maintain compliance: Place-of-service codes have been a compliance target for many years, says Bailey. Sometimes an office place-of-service is automatically pre-populated into a practice’s billing system. When this is the case, a coder must manually override the information to reflect that a service was performed in a facility setting. Coders must be cognizant of the setting in which a service takes place. This information ultimately affects what physicians are paid, and it can potentially leave them vulnerable to overpayments. It’s important to establish open lines of communication between the practice and facility so coders have the most accurate information possible.
Physical therapists—High use of outpatient physical therapy services What the Work Plan says: The OIG will determine whether therapy services provided by independent physical therapists were medically reasonable and necessary. The OIG will focus on those with a high utilization rate for outpatient physical therapy services.
How to maintain compliance: Medical necessity is key, says Bailey. With physical therapy, there is an expectation that patients will improve in a predictable period of time. Medicare also expects a physician to approve a specific plan of care with which therapy will be consistent. Physical therapists must provide as much documentation as possible to capture the patient’s improvement or lack thereof. For example, documentation to support the fact that a patient is progressing at a slower rate than anticipated is critical to help justify why additional therapy visits may be necessary.
Sleep disorder clinics—High use of sleep-testing procedures: What the Work Plan says: The OIG will assess the appropriateness of payments for high-use sleep testing procedures, including codes 95810 and 95811.
How to maintain compliance: The OIG is targeting repeated diagnostic testing performed on the same beneficiary when prior test results are still pertinent. Clinics must ensure that any and all tests performed are reasonable and necessary. The physician documentation and order must support this medical validation as well, says Bailey.
Tips for using the Work Plan
Take the following steps when the OIG releases its annual Work Plan
- Review the plan. What topics pertain to your specialty?
- What are the new issues? Many of the same issues repeat from year to year. Pay close attention to any new areas on which the OIG is focusing.
- Pull a sample of records and review for compliance as it relates to the OIG targets.
- Perform education to physicians and coders, if necessary.
- Perform a follow-up audit to determine whether the problem has been resolved.