View PDF

To prevent fraud and abuse within the Medicare and Medicaid programs, the Office of Inspector General's (OIG) 2004 Work Plan reviews areas for potential investigations. The OIG can levy varying degrees of sanctions for violations, such as program exclusions and monetary penalties arising under the Civil False Claims Act.

In 2003, the OIG excluded 1,241 providers from Medicare for fraud and abuse, convicted 320 for crimes against program rules and penalized 106 in civil actions. False Claims Act civil settlements monetary recovery was $156.7 million.

Listed below are some of the target areas with guidelines to follow:

PHYSICIANS:
Consultations: When billing a consultation, you must have a Request (written or verbal) from another physician; the service is Rendered to the patient; and a Report must be sent back to the referring physician. New patient visits and Counseling/Coordination of Care visits that do not follow the 3 R's of a consultation should be billed accordingly.

High Level Evaluation and Management (E&M) Services: The OIG will assess the adequacy of controls to identify physicians with aberrant coding patterns, specifically coding disproportionately high volumes of high-level E&M codes that result in greater Medicare reimbursement. In 2001, Medicare paid $23 billion in E&M services.

Documentation must always support the Evaluation and Management code that is being billed. It is also important to review the utilization of codes billed for your practice against other practices of your specialty.

Use of Modifier -25: If a patient's condition requires a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed, a 25 modifier can be utilized. If the E/M service is prompted by the symptom or condition for which the procedure and/or service was provided, a different diagnosis is not required for reporting the E/M service on the same date.

Use of Modifiers with National Correct Coding Initiative Edits: The CCI edits were designed to provide Medicare Part B carriers with code pair edits for use in reviewing claims. A provider may use modifier 59 (Distinct Procedural Service) to allow payment for both services within the code pair.

If the procedure is for a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury, a 59 modifier may be used. Documentation in the patient's record must support this information.

In 2001, Medicare paid $565 million to providers using the 59 modifier.

Place of Service Errors: The OIG will determine whether physicians properly coded the place of service on claims for services provided in ambulatory surgical centers and hospital outpatient departments. Higher payments are made for physician office services.

Document in the patient record whether the home health care plan was appropriate or if the proposed care plan needs to be modified to better meet the beneficiary's need. Keep a copy of the approved care plan in the patient's record and be prepared to provide supporting documentation if requested.

Billing for Diagnostic Tests: The medical necessity of diagnostic tests such as nerve conduction studies performed by physicians is under review. Nerve conduction study payments increased from $136 million in 2000 to $186 million in 2001.

Radiation Therapy Services:
The professional component of radiation therapy management is to be reimbursed as one billable unit of service for every five sessions of treatment.

Services and Supplies Incident to Physicians' Services: Direct supervision must be followed (a physician must be present in the office suite) in order to bill "Incident-to" and to be reimbursed 100% of the Medicare physician fee schedule.

HOSPITALS:
Consecutive Inpatient Stays: The OIG will review Medicare beneficiaries that received acute and postacute care through sequential stays at different hospitals. Payments may be denied when one or multiple stays constitute an attempt to circumvent the prospective payment system (PPS). Claims will be analyzed to identify questionable patterns of inpatient and long-term care.

Medical Necessity of Inpatient Psychiatric and Inpatient Rehab Facility Stays: Both inpatient psychiatric and inpatient rehab facility stays are being reviewed for medical necessity or coverage issues.

Medical reviews of outpatient psychiatric services provided by prospective payment hospitals and specialty psychiatric hospitals found very high rates of unsupportable or unallowable services.

Admission and discharge assessments for inpatient rehab must be entered and transmitted within defined time limits or payment is reduced.

Diagnosis-Related Group Coding: The OIG will review some acute hospitals that exhibit aberrant DRG coding patterns that increase reimbursement from Medicare. Some DRG's that have been reviewed for upcoding are 416 (Septicemia); 079 (Respiratory infections and inflammations); 475 (Respiratory system diagnosis with ventilator support) and 014 (Specific cerebrovascular disorders except TIA's).

Coronary Artery Stents: Medical necessity and supporting documentation will be reviewed for both inpatient and outpatient arterial stent implantations. Claims will also be reviewed for stent implantations that were performed during multiple surgical procedures to determine if they should have been performed simultaneously.

Diagnostic Testing in Emergency Rooms: Diagnostic testing such as x-rays, MRI's and CAT scans will be reviewed for medical necessity and if the testing coincided with the patient's treatment.

The additional target areas of the OIG Work Plan can be reviewed on their website, http://oig.hhs.gov/publications/workplan.html.