Q: What types of Medicare documentation and coding issues are likely to receive extra attention this year?

A: The Office of Inspector General annually publishes a work plan for the year that describes projects and areas of focus. Following is an abbreviated list of Medicare areas of focus that are important to most ophthalmic practices.

 • Consultations. Are they billed appropriately and if not, why? 

 • Evaluation and Management Services. Are physicians applying these codes properly? Particular attention will be paid to disproportionate utilization of high-level codes.

 • Modifiers –25 and –59. Are these modifiers used correctly? Modifier –25 facilitates payment of an office service on the same day as a minor procedure when the office visits represents a separately identifiable service. Was an unrelated service performed on the same day as a procedure when the office service is filed with modifier –25? Modifier –59 indicates that the two services were distinct and, although they're usually not reimbursed separately, circumstances exist that should allow for separate reimbursement. Were the circumstances appropriate to "unbundle" two services when the claim appends modifier –59? 

 • Place of service errors. Is the correct location of services (ASC or hospital outpatient department) identified on the claim form? 

 • Diagnostic Tests. Is medical necessity supported by medical record documentation? For instance, a worsening condition documented in the medical record will support medical necessity of diagnostic tests. 

 • "Incident to" services by technicians. "Incident to" services require direct supervision meaning that a physician is available in the clinic. Is the employee properly supervised to perform this service? Will the documentation support the claim?

This list is not exhaustive but is meant to provide targets for scrutiny affecting most ophthalmic practices. As you answer the questions raised by the OIG, consider your level of compliance in these areas. You can access the complete 2004 OIG work plan at http://oig.hhs.gov/publications/workplan.html.

Q: How much emphasis does the government put on recovery for Medicare fraud and abuse?

A: A very strong one. HHS and the DOJ's 2002 fiscal year report on the Health Care Fraud and Abuse Control Program cites the largest recovery of dollars since the program began in 1997: a record $1.8 billion won or negotiated in judgments, settlements and other means by the federal government in 2002. They report a return of $117 for each dollar spent on OIG audits, evaluations, investigations and other audit activities. This level of success reinforces the government's dedication to protect the integrity of the Medicare and Medicaid system by detecting fraud and abuse and prosecute violations.

Q: Should we be concerned about a "random" audit from our Medicare carrier?

A: A truly random audit has always been a rare occurrence. In October 2000, the Progressive Corrective Action (PCA) system was implemented. This transferred the responsibility of audits from local carriers to PSCs, or Program Safeguard Contractors. Unusual billing patterns target practices for review. The carrier flags a practice as an outlier based on utilization of CPT codes. Practices are often unaware that their utilization of services flags them as an outlier. CMS publishes utilization data on its website (cms.gov) that can be used for comparison.

Keep in mind, an outlier designation does not necessarily mean wrongdoing. For example, a glaucoma specialist is likely to draw attention due to an increased number of visual field tests performed when compared with a general ophthalmologist. The nature of the subspecialty and patient base may invite attention. If you know you are an outlier, focus your compliance efforts on those specific services in the event of a review.

Q: Has there been any activity regarding privacy compliance?

A: Apparently there has. The HHS Office for Civil Rights (OCR) is handling more than 2,800 complaints received as of November 2003, with approximately 100 complaints filed weekly. An OCR advisor indicated that about one-third of the complaints have been resolved, but details of the complaints have not been reported. Medical practices should continue to make every effort to comply with the HIPAA privacy regulation.

Q: What should be tracked and recorded in an internal compliance audit?

A: Your audit will reveal subjective and objective findings. Subjective include chart organization, legibility, completeness of registration forms, signatures by physicians and staff. Objective findings include over- or underbilling, modifier errors, diagnosis code errors, date errors, frequency of services, and necessity of services.

Q: How serious is a missing physician signature on patient chart notes?

A: The Medicare Program Integrity Manual (PIM) contains new material effective January 1, 2004. This new section includes a statement regarding signatures: "B – Signature Requirements. Medicare requires a legible identity for services provided/ordered. The method used (e.g. handwritten, electronic or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. … Providers using alternative signature methods (e.g. a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods.  … The individual whose name is on the alternate signature method bears the responsibility for the authenticity of the information being attested to. Physicians should check with their attorneys and malpractice insurers in regard to the use of alternative signature methods."

Q: What should we do after the audit is completed?

A: Problems identified in the review should be addressed. This may include refiling claims, making refunds, changing internal policies and staff training. Then, perform a repeat review that focuses on problems identified in the prior review. All practices should consider implementing a protocol for ongoing chart auditing. 

Ms. McCune is a vice president with the Corcoran Consulting Group, corcoranccg.com. Contact her at 1-800-399-6565 or dmccune@corcoranccg.com.