Healthcare Coding and Documentation 2011 Update - Part 5

For the most current information, view the Healthcare Coding and Documentation 2012 Update


2011 OIG Work Plan – Physician & Hospital  

2011 OIG Work Plan - Physician

  • Evaluation and Management (E/M) Coding and Electronic Health Record (EHR) Bonuses
    • Review E/M utilization to identify trends in the level of services
      • Certain providers billing lower or higher-level codes
    • Review documentation for E/M Services
      • To determine if identical or very similar documentation was used for different E/M codes
    • OIG believes the reliance on EHR systems’ automated documentation features may be causing improper payments based on identical documentation
  • EHR Bonuses and Attestation
    • OIG will check that those receiving bonuses have met meaningful use standards
  • Error-Prone Providers
    • Providers with high claims denial rates over the last four years
      • Will be singled out for medical claims review
      • Will receive overpayment demand letters
  • Coding of E/M Services
    • Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide
  • Place of Service Errors
    • Physician’s Office vs. Ambulatory Surgical Center (ASC) / Hospital Outpatient Departments
  • E/M Services Billed During Global Surgery Periods
  • Part B Imaging Services
    • Review whether the utilization rates reflect industry standards
  • Excessive Payments for Diagnostic Tests
    • Determine if testing was medically necessary
  • Trends in Laboratory Utilization
    • Will review types of lab tests ordered and number of lab tests ordered

2011 OIG Work Plan - Hospital

  • Medicare Excessive Payments
    • Hospitals required to report units of service as the number of times that a service or procedure was performed
      • Review outpatient claims in which payments exceeded charges and selected HCPCS codes for billings that appear aberrant
  • Medicare Disproportionate Share (DSH) Payments
    • Determine if payments were in accordance with Medicare methodology
  • Medicare Outlier Payments
    • Verify that outlier payments are based on the most recent cost-to-charge ratio from the cost report to properly determine outlier payments
  • Reliability of Hospital-Reported Quality Measure Data
    • Review hospitals’ controls for ensuring the accuracy of data related to quality of care
  • Hospital Readmissions
    • Readmitted to hospital less than 31 days after being discharged
    • Determine trends in the number of hospital readmission cases
    • Determine if the hospital services met professional standards of care
  • Payments for Diagnostic Radiology Services in Hospital Emergency Departments
  • Hospital Admissions with Conditions Coded Present-on-Admission (POA)
    • Determine which types of facilities and specific providers are most frequently transferring patients with certain diagnoses that were coded POA
  • Responses to Adverse Events in Hospitals
    • Determine whether hospitals have taken corrective actions and are in compliance with Medicare standards
    • Will identify and analyze potential overlaps, conflicts and gaps in responses
  • Hospital Reporting for Adverse Events
    • Review type of information hospitals’ internal incident-reporting systems capture


Contact Information

Steven Bisciello, MBA
Supervising Consultant, Healthcare Services Group  

Maureen Doherty, CPC, CPC-H
Supervising Consultant, Healthcare Services Group  

EisnerAmper LLP is an independent member firm of PKF International Limited


The material contained in this presentation is for general information and should not be acted upon without prior professional consultation. 

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