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March 27, 2018

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Medical Coding News Archives

OIG Issues Work Plan for 2016

November 30, 2015:

The Office of Inspector General (OIG)’s work plan for 2016 that it released in early November includes several new areas of scrutiny, with several items relating to medical devices and physician services.

Credits for replaced medical devices: Past OIG reviews have found that Medicare audit contractors have paid too much for device replacement reported on both inpatient and outpatient claims. Medicare payments for the replacement of implanted devices should be less than those for the initial implanted devices. Such devices may be replaced for any number of reasons, such as malfunction, recalls, or mechanical complications.

Payment levels for and medical necessity of orthotic braces: The OIG will compare the amount Medicare pays for orthotic braces with the amount other payers pay to identify any wasteful spending. It will also analyze the medical necessity of claims submitted by suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Past OIG reviews have found that some suppliers were billing for medically unnecessary DMEPOS, such as multiple braces or supplies for patients who were not seen by the referring physician.

Purchase versus rental of osteogenesis stimulators: The agency will examine whether renting these stimulators over 13 months, rather than buying them in a lump-sum payment, would save Medicare money. These bone-growth stimulators apply an electrical current to spur the healing of a fusion or fracture that fails to heal on its own.

Ventilator billing: Billing for ventilators has increased over the past few years, particularly under HCPCS code E0464 for a pressure support ventilator with a volume-control mode and noninvasive interface, such as a mask. In fact, allowed amounts for E0464 more than doubled between 2013 and 2014; the number of beneficiaries receiving pressure support ventilators also more than doubled, from 8,633 in 2013 to 19,085 in 2014. The concern is that suppliers are billing for ventilators for beneficiaries without life-threatening conditions. This violates the medical necessity criteria stating that ventilators are covered for treatment of severe conditions associated with neuromuscular and thoracic restrictive diseases and chronic respiratory failure associated with chronic obstructive pulmonary disease. Absent such life-threatening conditions, the more appropriate codes could be those for respiratory assist devices (RAD) or continuous positive airway pressure (CPAP) devices.

MS-DRG payment window: Past OIG audits have found that certain items, supplies, and services provided to inpatients that are covered under Part A are being billed separately to Part B. For this reason, the OIG will look at whether some outpatient claims billed to Part B for services furnished during inpatient stays were allowable under the prospective payment system or instead were included in the MS-DRG payment and shouldn not have been billed for separately.

Hospital quality reporting data: The OIG will evaluate the accuracy and completeness of the Centers for Medicare and Medicaid Services’ process for validating inpatient quality reporting data submitted by hospitals. Such data are used in CMS’s value-based purchasing program and the hospital acquired-condition reduction program.

Referring and ordering physicians: Physicians and nonphysician practitioners who order certain supplies, services, or DME are required under Medicare to be enrolled in Medicare and legally eligible to order or refer the beneficiary for such services or supplies. The OIG will verify that payments made for services, supplies, and DME ordered or referred by physicians and nonphysician practitioners comply with Medicare requirements.

Physician home visits: The OIG will examine whether evaluation and management home visits, versus office or outpatient visits, are documented as medically necessary. Medicare has paid more than half a billion dollars for home visits since January 2013.

Prolonged evaluation and management services: The OIG will examine the appropriateness of prolonged E/M services that are reported. The need for physicians to provide extended services beyond E/M is supposed to be rare and unusual. Such prolonged services include additional time beyond that spent during the usual companion E/M services.

SNF payment for therapy: The OIG has found that Medicare has been paying far more for therapy provided in skilled nursing facilities than such therapy costs SNFs to provide. The agency has also discovered that increasing numbers of SNFs are billing for the highest level of therapy even though beneficiary characteristics have not changed. In response, the OIG will study compliance with the SNF prospective payment system, particularly focusing on supporting documentation.

Quality oversight of ASCs: Past OIG reviews have found flaws in Medicare’s oversight of ambulatory surgery centers (ASCs), such as spans of five or more years between certification surveys, weak oversight of state survey agencies and ASC accreditors, and minimal information available publicly on ASC quality.

Payment to histocompatibility labs: The OIG will evaluate the compliance of payments to histocompatibility labs with Medicare requirements, namely that the cost reports are related to the care of beneficiaries and that the services were reasonable, necessary, and proper. The agency will also assess whether the cost information is sufficiently detailed and accurate.

Noncovered anesthesia services: The agency will determine whether, when receiving anesthesia services, the Medicare beneficiary had a related Medicare service, as Medicare will not pay for items or services that are not reasonable and necessary.


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