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Medical Coding News Archives

2014 OIG Work Plan Released: Physician Services Overview

February 13, 2014:

Karen Kachur, Clinical/Technical Editor

With the release of the Office of Inspector General’s work plan for 2014, providers have gained insight into what areas the agency will focus on this year. Ensuring they are not making any of the errors the work plan identifies will help providers avoid OIG scrutiny and audits.

The annual work plan outlines the objectives for each year’s review, which encompasses all of the 300 programs the Department of Health and Human Services administers, including Medicare and Medicaid services. In addition, the work plan includes reviews related to Medicare contractors, the Patient Protection and Affordable Care Act of 2010, and oversight of the funding HHS received under the American Recovery and Reinvestment Act of 2009.

OIG reported recoveries of more than $5.8 billion for fiscal 2013 consisting of nearly $850 million in audit receivables and approximately $5 billion in investigative receivables. It also identified savings of approximately $19.4 billion arising from legislation, regulatory changes, and administrative actions brought about by OIG recommendations.

As far as physicians are concerned, the OIG will initiate a review of claims for personally performed anesthesia services to verify that they complied with Medicare requirements and that modifier AA Anesthesia services performed personally by anesthesiologist, was correctly appended to the code for the service. An anesthesia service personally performed by the anesthesiologist is paid at a higher rate than is the same service provided under medical direction, which is reported using modifier QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals.

While inappropriate payments for evaluation and management (E/M) services has been a longstanding topic for OIG review, for fiscal 2014, the agency will concentrate on multiple E/M services linked to the same providers and beneficiaries. This review is based on Medicare contractors’ earlier observations noting an increase in the number of medical records with identical documentation across all levels of service. Providers are required to select the code for the service based on the specific service provided and to have documentation to support that level of service.

Also on the OIG’s radar will be the questionable billing of ophthalmology services that it uncovered in 2012. The agency will continue reviewing claims for inappropriate payments and/or questionable billing for these services and will determine the geographic locations of these providers.

OIG will also continue reviewing noncompliance with assignment rules. The agency plans to review physician and supplier participation in Medicare and accepted claim assignment during 2012, focusing on noncompliance with assignment rules and excessive billing of beneficiaries.

Also continuing into 2014 will be a review of physicians who improperly code nonfacility places of service on Part B claims. Medicare provides higher reimbursement for services performed in a nonfacility setting (e.g., physician’s office) than for services performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgery center.

Evaluation of Medicare payments to physicians, as well as hospital outpatient departments and independent diagnostic testing facilities will also continue due to the high utilization of sleep-testing procedures. The review will focus on the medical necessity and appropriateness of payments for these services.

Click here to read the work plan in its entirety.


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