Claim Errors and Audits
by Cheryl Nash
This is a short analysis of the 2013 Office of the Inspector General (OIG) work plan released showing the key items that they will be focusing on this year. As with each year, I try to review this to locate any items that may affect Phlebology in particular. This year’s has some interesting items that I wanted to bring to everyone’s attention.
The first one is the most exciting, Claims submitted by top Error-Prone Providers. The OIG “will review Medicare Part A and Part B claims submitted by error-prone providers to determine their validity, project our results to each provider’s population of claims, and recommend that CMS request refunds on projected overpayments.” They will identify providers that continuously submitted error-prone claims over the last 4 years, and will target these providers for estimated overpayments based upon entire claim history. They will then perform a review on a sample of claims to determine the extent of the inaccuracies. I cannot stress how important accurate coding and CPT reporting is, especially to Medicare. They do not look lightly upon an “I didn’t know” stance from a professional practice that should have the resources to ensure they are compliant. The penalties have the potential to be very costly. An internal policy of consistently reviewing the method of CPT reporting is highly recommended!
The second item to be on the lookout for is claims submitted as Incident-to Services performed by Non-Physicians. Most practices employ lower level providers to assist in patient care. These services are typically billed under Incident-to guidelines. The OIG “will review physician billing for “incident-to” services to determine whether payment for such services had a higher error rate than that for non-incident-to services.” It is recommended that you familiarize yourselves with these guidelines and turn a critical eye on the processes of your practice to determine compliance. Do remember, individual commercial payers also have guidelines for these services that do not always mirror Medicare, and these should also be reviewed.
The third issue I want to bring to your attention impacts every practice: Modifiers during the Global Surgery Period. “We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements.” This will mostly target Evaluation and Management codes, but will not be limited to them. Most providers I know are fairly confused on what does or does not constitute a separately identifiable E&M service. Most medical billers and coders are trained to make this determinationfor the provider prior to claim submission, but it would be beneficial to familiarize yourself with the rules of the road so to speak on global periods and what they encompass. A good resource is http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf See section 30.6.6. Other global modifiers to ensure compliance on are for surgical services performed during a global period that are separately payable. Most Phlebology providers perform some services that are considered Staged or Related (modifier 58), and ensuring proper use of the corresponding modifier is imperative to proper claim submission.
More detail on each of the above items, as well as the entire work order, can be found at:
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