News Brief: OIG 2001 Work Plan Targets OPPS

The Department of Health and Human Services Office of Inspector General (OIG) has released its work plan for fiscal year 2001. The work plan points out the areas the OIG will be looking at for strict enforcement, including areas it will audit to make sure the billing is correct. The OIG is already targeting the new Outpatient Prospective Payment System (OPPS).

The Office of Audit Services (OAS) will be looking at APCs. According to the work plan, The OAS conducts comprehensive financial and performance audits of departmental programs and operations to determine whether program objectives are being achieved and which program features need to be performed in a more efficient manner.
To check out the OIG work plan for 2001 go to www.oig.hhs.gov/wrkpln. The OIG will be focusing on:

Outpatient prospective payment system: If you thought you were going to get some time to adjust to APCs, you were wrong. The OIG will review implementation of the new prospective payment system for care provided to Medicare beneficiaries by hospital outpatient departments. Previously, Medicare paid outpatient departments their reasonable costs. The OIG says it will evaluate the effectiveness of internal controls intended to ensure that services are adequately documented, properly coded, and medically necessary. Controls over pass-through costs will also be reviewed.

Critical care codes (99291-99292): Critical care codes (99291, critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; 99292, each additional 30 minutes) are a new target area. OIG will examine the use of these two critical care codes that are appropriately billed to Medicare only if the patient is critically ill or potentially critically ill or unstable and requires constant attention by the physician. According to HCFA, the national Correct Coding Initiative (CCI) edits for services that are included in critical care relate to physician services only. The critical care edits have been removed from the CCI edits for APCs. All procedures performed and documented may be reported by the facility in addition to a critical care code, except for those procedures specifically bundled under critical care. In addition, the APC coding does not recognize the 99292 critical care additional minutes code. For example, for the patient who spends two hours in the emergency department receiving critical care and cardioversion, the hospital would bill 99291-25, (modifier -25, significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 92950 (cardiopulmonary resuscitation [e.g., in cardiac arrest]).

Role of nonphysician practitioners: The OIG will identify the scope of services that nonphysician practitioners provide to Medicare patients and determine what potential vulnerabilities may have emerged since the Balanced Budget Act of 1997. You [...]

- Published on 2000-12-01