Q Which agencies should we be concerned with that may be scrutinizing our documentation and coding?

A In addition to your local Medicare Administrative Contractor, there are several governmental agencies conducting reviews of documentation and coding issues. They include: 

Q Is there a listing of which issues are being scrutinized by these organizations? 

A Yes. Every fall, the OIG publishes a work plan that provides a detailed description of areas of focus for the coming year. Its report is public information and posted on its website at https://oig.hhs.gov. OIG also publishes a mid-year report to Congress, also on the website. 

The RACs are required to publish the issues under review on their respective websites; they are unique to each RAC. Check your RAC website to determine what the targets of focus in your locale are. 

A Place of service errors have been on the OIG’s work plan for the past three years and are an issue on several RAC websites. This is easily audited internally by confirming that the place of service on the submitted claim is accurate. Claims may be overpaid if reported as place of service office when the service was provided in the ambulatory surgery center or hospital outpatient department. 

Beware of practice management systems that default to place of service office (11). If data entry does not change this to POS ASC (24) or HOPD (22) for a laser or other surgery performed in the ASC or HOPD, an overpayment may result. 

Q Are drug payments to physicians still a concern for ophthalmologists and, if so, what steps can we take to improve compliance? 

A The continued increase in injectable drugs to treat various retinal conditions keeps the drug payment topic on the target list for scrutiny. Creating an inventory control system to track the use of injectable drugs can be useful as a means of improving compliance. It is important to be  sure that amounts used and wasted (if any) are noted on the operative report. 

Q If I own an optical dispensary and file claims for post-cataract eyeglasses, are there specific issues that involve this component of my practice?

A The OIG does intend to increase its onsite inspections for those revalidating supplier numbers. The primary focus of this effort is to find those individuals seeking a supplier number for a business that may not truly exist. 

Q If my optical shop is inspected, are there common errors made on post-cataract eyeglass claims that could jeopardize my reimbursement and re-enrollment? 

A Claim errors can be common in optical shops. For example, the POS on an optical claim is usually home (12), never office (11). The date of service on an optical claim is the date the eyeglasses are delivered, not ordered. There are also several forms that patients must sign and receive to maintain compliance. The absence of these forms could jeopardize your supplier number. 

Q Are there any documentation issues associated with diagnostic tests that could be viewed unfavorably by these agencies or any third-party payer audit?

A Yes, there are some documentation issues that you should be aware of. Diagnostic test interpretations should have substantive data. The Medicare Claims Processing Manual, as it relates to a test interpretation and report, states: “For example, a notation in the medical records saying ‘fx tibia’ or ‘EKG-normal’ would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An ‘interpretation and report’ should address the findings, relevant clinical issues, and comparative data (when available).” 

Q As we transition to electronic medical records, are there “red flags” that we should consider?

A Yes. The OIG is concerned about potential overpayments for office visits documented on electronic health records. The work plan states: “We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.”

Q Are any surgical services under the microscope for these agencies?

A The OIG has been watching and investigating services provided during the global surgery time frame and submitted with modifiers for reimbursement purposes. Of particular interest in ophthalmology is the use of modifier 25. This modifier is used to identify a “separately identifiable office visit” on the day of a minor procedure (e.g., punctal occlusion with plugs, foreign body removal, intravitreal injection). Reviews have revealed that, in many situations, a claim for the office visit is unwarranted and documentation does not support the use of modifier 25. 

A There are many steps you can take, including keeping informed about the issues. Much of the information about what is being targeted is public information and can be found on various government websites. Conducting regular chart reviews (internal and external), with a focus on the target areas, as well as services where you may have a higher frequency than your peers, can also help to insure compliance with new regulations.

Q Is this scrutiny likely to diminish over time?

A No. In 2011, under new rules authorized by the Affordable Care Act, the Centers for Medicare & Medicaid Services launched a new initiative called the CMS Fraud Prevention Initiative. In its announcement of this initiative, CMS said it aims to:

CMS is “mindful of striking the right balance between preventing fraud and other improper payments and maintaining the timely delivery of critical health care services to beneficiaries.” As such, CMS will continue working to “ensure that correct payments are made to legitimate providers for covered appropriate and reasonable health care services.”

Providers can learn more about fraud and submitting proper paperwork at www.stopmedicarefraud.gov/forproviders/index.html.  REVIEW