EyeNet Magazine

Savvy Coder: Coding & Reimbursement

What’s Under Investigation?:
Know the OIG’s Priorities for 2005

By David W. Parke II, MD, Senior Secretary for Ophthalmic Practice, and Sue Vicchrilli, COT, OCS, Academy Coding Executive

Each year, the Office of Inspector General identifies priorities in its ongoing campaign against fraud and abuse. In its latest work plan—which you can read in full at www.aao.org/aaoesite/coding —the OIG targets nine areas that will be of particular interest to ophthalmologists.

Billing service companies. The OIG will examine the relationships and arrangements that billing companies have with physicians and other Medicare providers and will determine the impact of those arrangements on the physicians’ billings.

Medicare payments to VA physicians. Physicians employed by the Department of Veterans Affairs may not bill Medicare for services rendered at any other facility during times that they were on duty at a VA hospital. The OIG will use VA documentation to assess the validity of Medicare reimbursement for services billed by physicians who receive remuneration from the VA. 

Physicians excluded from Medicare. In general, physicians who are excluded from federal health care programs are precluded from ordering or performing services for Medicare beneficiaries. The OIG will quantify the extent of services, if any, that have been ordered by those excluded physicians and the amount paid by Medicare Part B. 

Physician services at skilled nursing facilities. The OIG will investigate Medicare Part A and Part B claims with overlapping services for patients in a skilled nursing facility and will determine whether duplicate payments were made to either the physicians or the nursing homes for the same patient services. Physicians may bill Medicare for only  the professional component of a service on behalf of a patient in a skilled nursing facility. The technical component of physicians’ services is covered under the patient’s Medicare Part B stay in the skilled nursing facility and should not be billed separately by the nursing home.

Physician pathology services. Each year, Medicare pays physicians more than $1 billion for pathology services. This includes the examination of cells or tissue samples by a physician who prepares a report of his or her findings. The OIG will identify and review the relationships between physicians who furnish pathology services in their offices and outside pathology companies.

Physical and occupational therapy services. The OIG will examine Medicare claims for therapy services provided by physical and occupational therapists. This review will determine whether the services were reasonable and medically necessary, adequately documented and certified by physician certification statements.

Evaluation & Management services. The OIG will examine patterns of physician coding of E&M services and determine whether these services were coded accurately. In prior investigations, the OIG reported a significant portion of certain categories of these services was billed with incorrect codes, resulting in large overpayments. The OIG also will assess the adequacy of controls to identify physicians with aberrant coding patterns.

Modifier –25. The OIG will determine whether providers use modifier –25 appropriately. In general, a provider should not bill E&M codes on the same day as a procedure or other service unless the E&M service is a significant, separately identifiable service from such procedure or service.

Modifiers and National Correct Coding Initiative edits. The OIG will determine whether claims were paid appropriately when modifiers were used to bypass NCCI edits.

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