The Office of Inspector General’s Antifraud Campaign for 2013

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Each year, the Office of Inspector General (OIG) publishes a list of activities that it intends to investigate. Its current work plan includes five areas that are particularly pertinent to ophthalmologists.

Noncompliance with assignment rules and excessive billing of beneficiaries. Bottom line: Don’t balance bill. The OIG is determining to what extent Medicare Part B patients are inappropriately billed in excess of the amounts that are allowed. Its work plan notes that “Physicians participating in Medicare agree to accept payment on ‘assignment’ for all items and services furnished to individuals enrolled in Medicare.”

Place-of-service coding errors. Most surgical procedures are assigned more relative value units (RVUs) when performed in an office setting than in a hospital or an ambulatory surgical center (ASC). This is known as the site-of-service differential.

Potentially inappropriate payment for E&M services. The OIG will review records of multiple E&M services provided to the same patient by the same physician. Each chart note should reflect the work performed during the day’s encounter as it pertains to the chief complaint. If the documentation in an electronic heath record (EHR) is identical across services, that may suggest improper payments were made.

Use of modifiers during the global surgical period. Previous reviews by Recovery Audit Contractors uncovered incorrect billing of E&M and Eye code services provided during the global period. Under the concept of the “global surgical package,” all components of surgery that take place during the global period (including pre- and postoperative services) are bundled into one payment. For major surgery, the global period starts the day before surgery and ends 90 days after surgery; for minor surgery, it starts the day of surgery and, depending on the procedure, ends either the same day or 10 days later. If you perform an additional service during a procedure’s global period, you should only bill for it in certain circumstances. In these cases you append a modifier.

The four modifiers listed below are most likely to draw the OIG’s attention. They are used when a service is provided by the same physician or other health care professional during the postoperative period.

• –24 Unrelated E&M service during the global period

• –58 Staged or related procedure or service during the global period

• –78 Unplanned return to the operating/procedure room for related procedures during the global period

• –79 Unrelated procedure or service during the global period

You should conduct an internal chart audit to make sure your practice is applying these modifiers correctly. With regard to modifier –24, a new diagnosis code doesn’t necessarily indicate that the exam is unrelated to the surgery. Ask yourself whether the patient would be having the problem if it weren’t for the initial surgery.

Ophthalmological services—questionable billing. The OIG will review Medicare claims data to identify questionable billing for ophthalmological services during 2011. The OIG also will review the geographic locations of providers exhibiting questionable billing for such services in 2011.