EyeNet Magazine

Savvy Coder: Coding & Reimbursement
What Is Under Investigation in 2012? Lucentis, Avastin, Modifiers and More
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 identified scores of programs and activities that it plans to scrutinize in fiscal year 2012, several of which will be of particular interest to Eye M.D.s.

Lucentis and Avastin for Wet AMD

Acquisition costs and payments. Eye M.D.s use both Lucentis and Avastin to treat wet age-related macular degeneration (AMD). The OIG will review how physicians’ acquisition costs compare with Medicare Part B payments for the two drugs. Previously, CMS had enacted—and then reversed—a decision that reimbursement for Avastin should be reduced when used off-label to treat wet AMD. Why the U-turn? Physicians had argued that the reduced payments were too low and would require them to prescribe the higher-priced Lucentis. The purpose of the current investigation is to determine whether Medicare is paying substantially more than the acquisition cost for Avastin when it is being used off-label for wet AMD. The OIG will consider the additional cost of compounding Avastin.

Usage patterns and payments. The OIG will use National Claims History data to identify nationwide usage patterns and payments for Lucentis and Avastin in the treatment of wet AMD. It will then determine whether significant savings can be recognized if either one drug or the other is used more by ophthalmologists.


E&M Services

Potentially inappropriate payments. The OIG will review the extent to which CMS made potentially inappropriate payments for Evaluation & Management services and the consistency of E&M medical review determinations. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Cloned documentation is not appropriate.

Use of modifiers during the global surgery period. The OIG will tackle questions about the use of modifiers during the global surgery period (are they being used appropriately?) and about the resulting payments (have they been paid in accordance with Medicare requirements?).

Modifiers used during the global period are the following: –24 Unrelated exam during the global period, –78 Unplanned return to the operating/procedure room for related procedures by the same physician, –58 Staged or related procedure or service by the same physician, and –79 Unrelated procedure or service by the same physician. (Prior OIG work has found that improper use of modifiers during the global surgery period resulted in inappropriate payments.)


Also Under Scrutiny

High cumulative Part B payments. The OIG will review payment system controls that identify high cumulative Medicare Part B payments to physicians and suppliers. A high cumulative payment is defined as an unusually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary, over a specified period. Prior OIG work has shown that unusually high Medicare payments indicated that fraud or incorrect billing may have taken place. The OIG will now determine whether payment system controls are in place to identify such payments and assess the effectiveness of those controls.

Impact of physicians opting out of Medicare. The OIG will investigate the extent to which physicians are opting out of Medicare and whether those who have opted out continue to submit claims. As a result of entering into private contracts, physicians must commit that they will not submit a claim to Medicare for any Medicare beneficiary.  

Continued from the 2011 Work Plan. Compliance with assignment rules, incident-to services and place-of-service errors continue to be areas of investigation for the OIG (see the January 2011 Savvy Coder).

To read the OIG’s 2012 Work Plan in full, go to www.oig.hhs.gov and select “Reports & Publications” and “Work Plan.”


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