Medicare Compliance & Reimbursement

Next year you'll want to make sure you cross all your t's and dot all your i's, because the OIG has released its 2009 Work Plan -- which includes plans for reviewing Medicare claims for everything from the appropriateness of the GY modifier to diagnostic x-rays in the ED.

The Work Plan: The OIG Work Plan details issues that the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General will address during the fiscal year.

The Work Plan may indicate focus areas for future audits. "When the OIG targets a specific area in the Work Plan, it means that the OIG is turning its attention to that specialty," says Andrea Somowski, a billing consultant in Raleigh, NC.

One of the OIG's 2009 targets is to "examine provider usage of procedure codes for services not listed in the HCPCS," according to the Work Plan.

"Most likely, the OIG wants to make sure that practices are only using unlisted codes when no other codes apply, and that they aren't billing unlisted codes as a cover for procedures that aren't payable by Medicare," says Randall Karpf of East Billing.

The OIG also intends to "review the appropriateness of providers' use of modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) on claims for services that are not covered by Medicare," the report states.

By law, Medicare excludes some medical treatments, such as many screening tests, and you might want to inform patients of this fact. Although you're not required to issue a notification (Notice of Exclusions from Medicare Benefits, or NEMB) for excluded procedures, doing so is a courtesy to the patient and may help the process of collecting from the patient. In these cases, modifier GY is applicable.

However, Medicare denied over $400 million in modifier GY claims in 2006, and the OIG wants to further research "patterns and trends for physicians' and suppliers' use of modifier GY," the report notes.

The Work Plan notes that the OIG will also hone in on entities that are billing high volumes of ultrasound services and will investigate the medical necessity of these ultrasounds, the Work Plan indicates.

"In areas of high utilization of ultrasound services, we will examine service profiles, provider profiles, and beneficiary profiles," the OIG states.

As in prior years, the OIG plans to keep an eye on incident-to services -- those visits performed by nonphysician practitioners, but billed as if the physician performed the service personally.

"These services may be vulnerable to overutilization or put beneficiaries at risk of receiving services that do not meet professionally recognized standards of care," the Work Plan states.

The OIG will look at the nonphysician practitioners' qualifications and will investigate whether the qualifications are consistent with "professionally recognized standards of care."

"This is a common theme with the OIG," says Somowski. "They want to look closely at incident-to, so keep an eye on your nonphysician documentation to make sure it's very tight," she advises.

Read the 2009 Office of Inspector General Work Plan, visit the OIG Web site at http://www.oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf.