Healthcare Coding & Documentation 2012 Update - Part 4


2012 OIG Work Plan – Physician
  • High Cumulative Part B Payments
    • Unusually high payment made to an individual physician or supplier over a specified period
      • May indicate incorrect billing or fraud and abuse
  • Impact of Opting Out of Medicare
    • Review whether physicians who have opted out of Medicare are submitting claims to Medicare
  • Chiropractors – Part B Payments
    • Manual manipulation of spine - Only approved treatment
    • Maintenance therapy – Non-covered service
  • Evaluation & Management (E/M) Services
    • Trends in Coding Claims
    • Use of Modifiers During Global Surgery Period
    • Potentially Inappropriate Payments
      • E/M Medical Review Determinations
      • Electronic Health Record Reviews
        • Identical Documentation Across Services
  • Outpatient Physical Therapy Services
    • Reasonable and Medically
    • Necessary Proper Documentation
  • Diagnostic Radiology – Excessive Payments
    • High-cost Diagnostic Radiology Tests
      • Medical Necessity
      • Same diagnostic tests ordered for a beneficiary by PCP and specialists for the same treatment
  • Laboratory – Glycated Hemoglobin A1C Tests
    • In excess of Medicare Guidelines
      • Every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of National Coverage Determination (NCD) guidelines
2012 OIG Work Plan – Ambulatory Surgery Centers (ASC)
  • Payment System
    • Review appropriateness of Medicare's methodology for setting ASC payment rates under the revised payment system
  • Safety and Quality of Surgery and Procedures
    • ASC and Hospital Outpatient Departments
    • Scheduled for 2013
      • Care in preparation for and during surgeries
      • Adverse events
2012 OIG Work Plan – Hospital
  • Accuracy of Present-on-Admission (POA) Indicators
    • Diagnoses POA vs. Conditions Developed During Stay
  • Inpatient and Outpatient Payments to Acute Care Hospitals
    • Identify providers that routinely submit improper claims
    • Areas that are at risk of non-compliance with Medicare billing requirements
    • Review hospitals' policies and procedures for comparison of compliance practices
  • Hospital Inpatient Outlier Payments: Trends and Characteristics
    • High or Increasing Rates of Outlier Payments
    • In 2009 – Outlier Payments represented 5% of total Medicare inpatient payments $6 billion per year
  • Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care
    • Examine the relationship
      • Financial or Common Ownership
    • Medicare reimbursement
      • Acute-care setting to other settings
  • Inpatient Prospective Payment System (IPPS): Hospital Payments for Non-Physician Outpatient Services
    • Submission of additional claims to Part B are prohibited
    • Prohibits separate payments of OP diagnostic services and admission-related non-diagnostic services rendered up to 3 days before the dates of admission
  • Non-inpatient Prospective Payment System: Hospital Payments for Non-Physician Outpatient Services
    • Review services rendered up to 1 day before and on the date of admission
  • Observation Services During Outpatient Visits
    • Improper use of observation services may subject beneficiaries to high cost sharing


Contact Information 

Steven Bisciello, MBA EisnerAmper, LLP Manager, 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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