EyeNet Magazine

Savvy Coder: Coding & Reimbursement
Be Forewarned About the OIG’s Investigative Priorities for 2011
By Sue Vicchrilli, COT, OCS, Academy Coding Executive, and David A. Durfee, MD, Senior Secretary for Ophthalmic Practice
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The Office of Inspector General (OIG) has announced the activities it plans to scrutinize in 2011. Many aspects of E&M documentation are high on its list of priorities. Here are nine areas of investigation that will be of particular interest to ophthalmologists.

E&M in the Spotlight

Correct level of exam, complexity and patient status. Physicians are ultimately responsible for ensuring the exam codes submitted accurately reflect the services provided. Because Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments, the OIG wants to confirm that the level of exam, the complexity of services provided and the patient status (e.g., new or established) are all correct.

Cloned documentation, and EHR documentation. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. The OIG states that it also will review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.

Medicare payments for claims deemed not reasonable and necessary. These claims may be identified by modifier –GA, which indicates you have an Advance Beneficiary Notice on file. The OIG will determine the extent to which Medicare paid for Part B claims with these modifiers, as well as the types of providers and the types of services associated with these claims. The OIG also will assess the policies and practices that Medicare contractors have in place with regard to these claims.

E&M services during global surgery periods. The OIG will continue to review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E&M services provided during the global surgery period. The OIG will determine whether industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.


Still Under Investigation

Place-of-service errors. Medicare pays the surgeon a higher amount when a surgery is performed in the office than when it is performed in an ASC or hospital outpatient setting. This is known as the site-of-service differential. The OIG will determine whether physicians are properly coding the place of service.

Medicare providers’ compliance with assignment rules. It is a violation to “balance bill” Medicare patients in excess of amounts allowed by Medicare.

Medicare billings with modifier –GY. In fiscal year 2008, Medicare received more than 75 million claims with a modifier –GY, totaling approximately $820 million. The OIG will examine patterns and trends for physicians’ and suppliers’ use of modifier –GY.

Payments for services ordered or referred by excluded providers. No payment should be made for any items or services furnished, ordered or prescribed by an excluded individual or entity. The OIG willine improper payments for services based on orders or referrals by excluded providers.

Medicare services billed with dates of service after beneficiaries’ dates of death. The Federal Claims Collection Act of 1966 requires the recovery of overpayments made for services submitted with a date of service that is after the patient’s date of death.

Read the Full Work Plan

To view the 2011 Work Plan in its entirety, go to www.oig.hhs.gov, select “Publications” and then “Work Plan.”


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