The Watchful Eye of the Government – Understanding The Office of Inspector General Work plan
Kathe J. Barrett, CMC
Lemons, DeGroot and Olivas L.L.C.
Each fiscal year, the Health and Human Services (HHS) Office of Inspector General publishes a work plan for the upcoming fiscal year. This document highlights the projects assigned to various agencies under the umbrella of the OIG and describes the details of that project. This document is of vital importance to healthcare providers as it can give you a head start on internal audit of your billing and coding compliance.
The document can be accessed at: http://oig.hhs.gov/publications/workplan.html
It is an Acrobat Reader file that can easily be downloaded through the internet. The document is divided into various provider types and agencies with sub-topics on the various projects that have been assigned to that department.
Projects for FY2007 under the Medicare Physicians and Other Health Professionals category include:
- Billing Service Companies
- Physician Pathology Services
- Cardiography and Echocardiography Services
- Physical and Occupational Therapy Services
- Payment to Providers of Care for Initial Preventive Physical Examination
- Part B Mental Health Services
- Wound Care Services
- Evaluation of “Incident to” Services
- Potential Duplicate Physical Therapy Claims
- Eye Surgeries
- Place of Service Errors
- Review of Evaluation and Management Services During Global Surgery Periods
- Psychiatry Services Provided in an Inpatient Setting
- Medicare Reimbursement for Polysomnography
- Long Distance Physician Claims Associated with Home Health and Skilled Nursing Facility Services
- Violations of Assignment Rules by Medicare Providers
- Advanced Imaging Services in Physician Offices
You may be thinking to yourself, “none of these subjects affect me or my practice,” think again! Here is the description of the Place of Service Errors – this particular project can affect many different provider types especially surgeons.
Place of Service Errors
This review will determine whether physicians properly coded the place of service on claims for services provided in ambulatory surgical centers and hospital outpatient departments. Medicare regulations provide for different levels of payments to physicians depending on where the service is performed. Medicare makes higher payments for physician office services. (OAS; W-00-06-35113; various reviews; expected issue date: FY 2007; work in progress)
The OIG at the Federal and State level has very sophisticated data mining systems that review claims submitted for processing with Medicare and Medicaid. Any provider is subject to review and audit by the Agency.
Visit and review the OIG work plan at lease twice a year. The initial plan is published in late summer and an update is published in the spring. Keeping on top of these topics can keep you and your practice out of trouble by ensuring you meet the regulatory requirements of the Government.
Resources: OIG 2007 Work plan
MEDICARE ANNOUNCES THE START OF 2007 OPEN ENROLLMENT FOR MEDICARE HEALTH AND DRUG COVERAGE
Expanded Options Provide More Comprehensive Coverage for Millions
The Centers for Medicare & Medicaid Services (CMS) has announced that Medicare beneficiaries have six weeks to change or add coverage to their current Medicare health and prescription drug plans. The Medicare enrollment period runs through December 31, 2006.
“Now is the time for Medicare beneficiaries to carefully review their current plan to see how changes may affect their costs and coverage in 2007, and then compare their plan to other options available to them,” said Health and Human Services Secretary Mike Leavitt. “If they are satisfied their plan will meet their needs next year, they do not need to take any action to keep their coverage.”
“Again this year, Medicare and its network of dedicated and trained national, state and local partners are providing highly personalized information and assistance to beneficiaries in their communities, online and on the phone,” said Leslie V. Norwalk, Acting Administrator for CMS. “Building on last year’s successes and experiences, beneficiaries and those who are assisting them have access to a variety of consumer tested tools and resources which have been enhanced to help them make confident, well-informed decisions about their health and prescription coverage in 2007.” Online alone, 16,000 beneficiaries enrolled in drug plans in the first 24 hours of open enrollment.
CMS is adding a new consumer tool today focusing on plan performance. Medicare Part D Plan Performance metrics for 2006 are now posted on the Plan Finder Website. Consumers are able to see how plans are rated along with specific data on how they performed on the following areas of customer service, including: telephone customer service, complaints, appeals, and sharing information with pharmacists.
In addition to the website enhancements, tools and resources such as the 2007 Medicare & You handbook, www.medicare.gov, and 1-800-Medicare, there are community-based information and enrollment events scheduled, and the Medicare “Mobile Office Tour” has a full schedule of stops planned to help local partners and community organizations with enrollment events.
Competition and choice have resulted in the average monthly premium of $24 for 2007, the same as in 2006, and 83 percent of beneficiaries with stand-alone prescription drug plans will have access to plans that cost less than their current coverage. Nationwide, the average number of drugs included on plan formularies have increased by 13 percent, and there are more plans with coverage for preferred brands and/or generics in the coverage gap, with at least one available in every state. On average, beneficiaries are saving more than $1,200 annually on their drug costs, and five separate opinion surveys show that beneficiaries are overwhelmingly satisfied with their Part D coverage. While beneficiaries have until December 31 to change or choose, CMS officials encourage those who plan to make changes or join to do so early—optimally by December 8—to avoid any delay or inconvenience in accessing their coverage in January.
“With the great success of the initial year for Medicare prescription drug coverage, this year’s open enrollment period is focused on improving beneficiary satisfaction by providing options for more comprehensive coverage and competitive costs while assuring a smooth transition for those who select a new plan,” stated Norwalk. She says
CMS continues to work with plans and inter-governmental partners on complaint resolution and systems integration for data exchanges to process enrollments smoothly, accurately and efficiently.
Optimize Reimbursement with Proper Usage of the -25 modifier
Ruth Ann Yoder, CMOM
Unfortunately, coding and documentation rules are not simply black and white, are subject to many interpretations. Coding is a very "fluid science" which constantly evolves and changes. The various Medicare carriers differ in their medical policies for coding and documentation of the identical patient encounter. This variability requires the coder or biller to keep abreast of the rules for particular carriers, and apply the appropriate requirements for coding and documentation promulgated by that carrier.
The importance of a detailed medical record documentation was correctly emphasized in medical school. A detailed medical record is required to satisfy insurance carriers that all services were provided to a patient were both medically necessary and actually performed. In addition, each state licensing board describes the minimum requirements for a patient’s medical record. Failure to maintain appropriate medical records can be grounds for the loss of a medical license.
There are many arenas I could write about when it comes to medical documentation guidelines and usage of modifiers. In this article, it is my purpose to review the proper usage of the -25 modifier.
The -25 modifier was clarified in the 1999 AMA CPT Manual with assistance from the late Doug Sowell, DPM, the former APMA Health Policy Committee Chairman and the APMS president. Dr. Sowell was the first podiatric member of the AMA CPT Editorial Panel and he was the Co-Chairman of the Health Care Professional Advisory Committee (HCPAC). His work made it clear that an E/M could be paid with a procedure even if the procedure and the E/M were prompted by the same diagnosis.
New language for CPT 2006 makes it clear that the level of E/M selected must be substantiated based on an understanding of the CMS E/M guidelines.
The -25 modifier is appropriate to append to an E/M service performed at the same time as a minor surgical procedure; however, the documented E/M service must be significant and separately identifiable from the procedure. The -25 modifier is appended to the E/M service when either:
1) A significant separately identifiable E/M service is performed that is unrelated to the minor surgical procedure being performed at the same time. In this case, both the E/M code and the procedure code are linked to two different ICD-9 (diagnosis) codes or:
2) A significant separately identifiable E/M service is provided which goes above and beyond the usual E/M that is “built into” every minor surgical procedure. Believe it or not, all surgical procedures have inherent E/M value “built into” their relative values. To be eligible for an E/M service to be billed with a -25 modifier, the E/M service must be considered to be above the usual amount of E/M included with the typical performance of the procedure. In this case, both the E/M code and the procedure code are linked to the same ICD-9 (diagnosis code).
Example of the Appropriate Use of the -25 Modifier
An established patient presents to the office with either a new complaint, or a previously successfully treated complaint that is now exacerbating after a long quiescent interval. This might be a patient discharged for heel pain six months previously who is having a relapse of heel pain for which is determined (based on the evaluation) that a procedure is appropriate. An interim history and physical exam is required to properly manage this complaint.
This interim H and P requires one to perform and document two of the three elements of an E/M encounter (the history, exam, and decision making) in order to make this diagnosis and determine the treatment plan. The -25 modifier is then appended to the E/M code in addition to billing for the minor surgical procedure. The level of exam, which is documented and billed, must be medically necessary and related to the patient’s problem.
Another example of the appropriate use of the -25 Modifier
A new patient presents to the office for consultation and advice on referral of their primary care physician. The purpose of the consultation is to review the treatment plan already established by the primary care physician and recommend future treatment for a heel ulcer and return the patient back to the primary case physician, it at all possible. Proper medical management of this problem requires an H and P in order to diagnose this patient’s complaint prior to performing any necessary surgical procedures, such as wound debridement.
The -25 modifier is appended to the E/M code in addition to billing for any procedure codes when the EM service is documented. The level of exam must be medically necessary and related to the problem; however, if medically necessary, and documented properly, an auditor should allow additional exam elements to be performed that are not obviously related directly related to the problem. One would have to document that the preliminary history or exam dictated an area of concern which required further evaluation.
Example of Inappropriate Use of the -25 Modifier
A treatment plan is discussed with the patient and agreed upon at the initial E/M encounter for this new problem. This treatment plan calls for a series of three injections that will start immediately to treat the symptoms associated with a neuroma.
It would be incorrect to bill an E/M visit with the -25 modifier in addition to the injection for each patient encounter after the first encounter. The treatment plan for a neuroma usually demands the series of three injections to be carried out regardless of the patient’s response to therapy.
The interim history, interim exam, and decision making are included in the payment for the injection unless:
1) The patient is worse and the primary diagnosis must be reconsidered, requiring obtaining additional history and exam, or
2) The patient develops an untoward reaction to the injection that requires re-evaluation, or
3) Other treatment options such as surgery are explained to the patient in detail and are properly documented in the medical record.
Caution: Use of the -25 modifier is regularly monitored by carriers for over-utilization. Therefore, the provider should only use the -25 modifier when appropriate and document the service correctly. Frequent use of the -25 modifier has been considered a willful attempt by the physician to gain additional reimbursement and an act of fraud.
Coding Hint: Consider the patient medical record with a -25 modifier as having two distinct sections: the procedure portion and the E/M portion. Mentally, strike out the portion of the record that is directly related to the procedure. The remaining information must substantiate the E/M encounter at the level billed by the provider.
