Inpatient Facility Coding & Compliance Alert

Tune in to 6 additional watch items.

On May 28, 2015, the Office of the Inspector General (OIG) published a mid-year update to its Fiscal Year FY 2015 Work Plan. This mid-year update removes items that have been completed, postponed, or canceled and includes new items that have been started after the 2015 work plan was published in October 2014. (Read “Plan Ahead for the Issues Within the OIG’s 2015 Work Plan” in the IFC Volume 4, Number 1.)

Take the Pulse of the Updated Work Plan

There are many new items on the agency’s agenda, most of which are scheduled for 2016. For Medicare alone, the OIG has added several additional watch items.

1) Intensity-modulated radiation therapy (IMRT): OIG will review Medicare outpatient payments for IMRT to determine whether the payments were made in accordance with federal rules and regulations.

Background: IMRT is an advanced mode of high-precision radiotherapy that uses computer-controlled linear accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. Prior OIG reviews did identify hospitals that incorrectly billed for IMRT services. OIG also found out that certain services are not to be billed when performed as part of developing an IMRT plan.

Impact to you: Hospitals should be aware that the OIG intends to review Medicare outpatient payments for IMRT beginning in 2016. Since prior OIG reviews have identified hospitals that have incorrectly billed for IMRT services, you must therefore ensure you complete your bills accurately so that they can be processed correctly and promptly. “IMRT has long been a recognized coding and billing challenge. While the clinical records are usually complete, translating them into proper claims is often problematic,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA.

2) Hospital preparedness and response to high-risk infectious diseases: In order to ensure quality of care and patient safety in hospitals, the OIG will determine hospital use of HHS resources and identify lessons learned through recent experiences with pandemic or highly contagious diseases, such as Ebola. This analysis is scheduled to begin in 2016.

Background: Prior OIG work identified shortcomings in areas such as community preparedness for a pandemic and hospital preparedness for natural disasters (i.e., Superstorm Sandy, 2013). OIG will therefore analyze whether there was a judicious, planned and efficient hospital use of resources available from the Department of Health and Human Services. 

Impact to you: If you have not started already, chart out a strategic plan to deal with the possibility of public health emergencies resulting from infectious diseases. Several HHS agencies, including the Centers for Disease Control and Prevention (CDC), the Office of the Assistant Secretary for Preparedness and Response (ASPR), and CMS provide guidance and support for hospitals as they prepare for such situations.

3) Access to durable medical equipment in competitive bidding areas: In 2016, the OIG will also determine the effects of the competitive bidding program on Medicare beneficiaries’ access to certain types of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). 

Background: In the past, competitive bidding has led to reduced access to DME and, in turn, compromised the quality of care beneficiaries receive. In an effort to reduce waste, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) updated Medicare’s payment system for certain DMEPOS from a fee schedule to a competitive bidding program. Under this program, DMEPOS suppliers compete on price to supply to particular geographic areas.

Impact to you: If you can, keep a check on adequate availability of durable medical equipment for your patients. You may also develop a simple feedback system wherein patients may report a difficulty in access to the DMEs. “Hospitals and other DME suppliers should keep careful records for any sort of shortfalls in availability,” advises Abbey.

4) Clinical laboratory payments: The OIG plans to conduct in 2016 an annual analysis of Medicare payments for clinical diagnostic laboratory tests including the top 25 clinical diagnostic laboratory tests by Medicare.

Background: Previous OIG work found that Medicare pays more than other insurers for certain high volume and high expenditure laboratory tests. Under the Section 216 of the Protecting Access to Medicare Act of 2014 (the “Act”), starting in 2017, Medicare payment rates for laboratory tests must be based on private payer rates. The Act also establishes processes for determining initial payments for new laboratory tests. Pursuant to a requirement of the Act, OIG will conduct an annual analysis and monitor Medicare expenditures and the new payment system for laboratory tests. 

Impact to you: Keep abreast of the new Medicare payment rates for laboratory tests beginning in 2017 based on private payer rates. Based on the new system, you may then establish processes for determining initial payments for new laboratory tests. “Also, note that the Medicare’s OPPS (Outpatient Prospective Payment System) now bundles certain laboratory tests. This new bundling process may make it even more difficult to accurately judge laboratory payments,” adds Abbey.

5) Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) requirements: In 2016, the OIG plans on reviewing compliance with various aspects of the IRF PPS, including the documentation required in support of the claims paid by Medicare, to determine whether IRF claims were paid in accordance with federal laws and regulations.

Background: IRFs provide rehabilitation for patients recovering from illness and surgery who require an inpatient hospital-based interdisciplinary rehabilitation program, supervised by a rehabilitation physician. Effective for IRF discharges on or after January 1, 2010, IRFs must ensure that all documentation and coverage requirements set forth in 42 CFR § 412.622(a)(3), (4) and (5) are met to ensure that the IRF care is considered reasonable and necessary under the Social Security Act (the Act), § 1862(a)(1)(A). 

Impact to you: If you belong to an IRF, it’s time to go through the above mentioned documentation and coverage requirements, and safeguard your revenue. Look forward to a summarized version of these requirements in the forthcoming issue of Inpatient Facility Coding and Compliance Alert.

6) Use of electronic health records (EHR) to support care coordination through accountable care organizations (ACO): The OIG will review in 2016 the extent to which providers participating in ACOs in the Medicare Shared Savings Program use EHRs, to exchange health information, for achieving their care coordination goals. 

Background: The Medicare Shared Savings Program promotes accountability of hospitals, physicians, and other providers for a patient population, coordinates items and services, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery. The agency will also assess providers’ use of EHRs to identify best practices and possible challenges in their progression toward interoperability, or the flexibility with which information systems can exchange data and have the ability to interpret those shared data.

Impact to you: You should already be working on EHRs. Just do it well, striking a balance between interoperability and safekeeping of the protected health information (PHI).

Practical takeaway: An eclectic approach might be your best strategy for staying clear of the OIG’s radar. “Some of the processes and procedures are vendor specific,” says Abbey. 

Draw from various sources, introspect, and see how others are doing. OIG’s Work Plan should not be the only compliance guidelines one should use for its internal initiatives, but OIG’s impetus on specific new risk areas can help you shape your practice’s compliance program not only over the ensuing months but also for the upcoming year 2016.

To read more, go to http://oig.hhs.gov/reports-and-publications/workplan/index.asp#current.