October 2003

What OIG will eye in 2004

The work plan developed by the Office of Inspector General (OIG) of the Department of Health and Human Services identifies a number of areas that will be under scrutiny throughout 2004. A number of these areas may be of special interest to chiropractors:

• Consultation services. OIG will undertake a study to determine the appropriateness of billings for physician consultation services and the financial impact of inaccurate billings on the Medicare program. According to OIG, in 2000, allowed Medicare charges for consultations totaled $2 billion.

• Coding of E and M services. OIG will examine physician coding for evaluation and management services, whose Medicare reimbursements totaled more than $23 billion in 2001. OIG plans to assess the adequacy of controls to identify physicians with aberrant coding patterns, especially those who have a disproportionately high volume of high-level E and M codes that result in greater Medicare reimbursement.

• Use of modifier –25. OIG also wants to determine if modifier –25 is being used appropriately. As stated in the work plan, “A provider should not bill evaluation and management codes on the same day as a procedure or other service unless the evaluation and management service is unrelated to such procedure or service. A provider reports such a circumstance by using modifier –25.”

In 2001 Medicare allowed more than $1.7 billion for E and M services billed with modifier –25. OIG will determine whether these claims were billed and reimbursed appropriately.

• Billing for diagnostic tests. OIG will assess the medical necessity of diagnostic tests, such as nerve conduction studies, performed by physicians. According to OIG, Medicare covers a range of diagnostic tests, including nerve conduction studies, and Medicare-allowed amounts for nerve conduction studies increased from $136 million in 2000 to $286 million in 2001 — approximately 37 percent. OIG wants to determine the cost of any medically unnecessary and incorrectly paid nerve conduction studies.

• Use of modifiers with NCCI. In 2003 Medicare began a National Correct Coding Initiative (NCCI) by posting its edits on the Web. (See “CMS coding edits on Internet” in the news on www.ChiroEco.com). OIG plans to assess whether claims were paid appropriately when modifiers were used to bypass NCCI edits.

• Long distance physician claims. The agency will review Medicare claims for face-to-face physician encounters in which the practice setting and the beneficiary’s location were separated by a significant distance. It will seek to confirm that services were provided and accurately reported.

Source: Office of Inspector General, Health and Human Services, www.oig.hhs.gov

Industry News from:
Chiropractic News from: