Medical Coding Updates: Bulletproof Your Neurology Practice with This Insider Info on OIG Workplan

We can refer Office of Inspector General as the watchdog for Medicare. And they put out a work plan each year. And the OIG has a responsibility to report its findings to the Secretary of HHS and to Congress. It carries out its duties through audits, investigations, and inspections, that annual work plan describe areas of interest. Particularly they look at things that have had tremendous increase in utilization, frequency of reporting or increase in expenditures. That's usually some of the top items.

They also have some other areas. But they publish those areas. Many healthcare practices use this as a basis for their own compliance, internal looking to see how well they follow against or match up against some of the top items.

Remember that each year, we may not get entirely new ones. Sometimes the work plan item is continued on. They haven't finished their research. And there are audits of the area.

The medical coding updates require that it's important to accurately report that place of service code especially for those neurology practices who see patients in a facility outpatient department rather than having their own office setting. For example in 2009, the national Medicare allowable for 992 and 993 in a facility is $44.72. So, if it's a site of service 22, hospital outpatient as compared to an office site of service 11 it's $61.31.

Likewise for a greater occipital nerve injection, the facility allowable would be $68.53 compared to $94.86 in an office. So we understand that Medicare guidelines allow a much higher practice expense for providers that are performing services in their own office where they bear those expenses as compared to services that are performed in ASCs, hospital outpatient. So, this is the one of the areas that they're looking at. So it's good to make sure that your coders and your billers primarily are reporting the correct site of service so you're paid accurately.

We have a new one, physician Medicare services performed by non-physicians. These are physicians that are billing Medicare but do not personally perform these i.e. incident-to services. So, they're going to be looking at incident-to services, specifically be vulnerable to overutilization or put beneficiaries at risk of receiving services that don't meet professionally recognized standards of care.

They're going to be looking at the qualifications of a non-physician staff and whether these qualifications are consistent with professionally recognized standards of care. Remember our incident-to requirements in order to compliantly report incident-to services to Medicare?

It has to be in a established patient, seen for a condition within the established plan of care, and it has to be a supervising physician within that office suite during the incident-to services. So it can't be a new patient, not a consult patient, no new problems. And we have to have a supervising physician within that office suite.

We have a continuation of the work plan, that reassignment of benefits. Again, this was prompted because of an investigation in South Florida that fraudulent providers were identifying information from physician. They're going to look at Medicare payments for unlisted procedure codes.

They want to look at the accuracy that Medicare carriers are paying for them and also coverage. They'll also examine provider usage of the procedure code not listed in the HCPCS or CPT medical coding. They're going to look at - new for Medicare, billings with the modifier GY. Medicare GY is used to indicate that an item or service statutorily excluded or doesn't meet the definition of any Medicare benefits.

And last but not least - this isn't under Medicaid services, providers billing for more time than feasible in one day. We all need to remember that there are only 24 hours in each day. They identified a problematic provider that was billing for the equivalent of 70 to 80 hours in one day time, primarily E/M services that was based on time. So it's important that we double check to make sure that we're not billing for more.

Our expert in a medical coding conference cited a report of OIG work plan Medicare payments for interventional pain management procedures was listed and reported in September 2008. And it has surround these facet joint injection. Payments rose from 2003 $141 million dollars to $307 million in 2006. During that same period of time there were 76% increase in reporting, these are things that perk the OIG's interest.

Their findings were that 63% didn't meet Medicare's program requirement. There is a multitude of breakdown of that. We want to point out that 73% of neurology specialty claims reviewed for facet joint injections in an office setting were found to be in error.

These were primarily driven around reporting bilateral facet joint injections incorrectly, reporting them as an add-on level rather than reporting them with a modifier -50. So, if we're doing L4-L5 bilaterally, we're going to report that 64475 with a -50 modifier. Incorrect would be 64475 and 64476. So, it's important to check your facet joint to ensure accurate medical coding and billing. The OIG has charged our Medicare carriers to go back and look at those.

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