Ob-Gyn Coding Alert

The items the Work Plan outlines go beyond the typical E/M issues.

This year, you’ll want to make sure you button up your ultrasound medical necessity, because the OIG has released its long-awaited 2014 Work Plan — which includes plans to review Medicare claims for everything from laboratory tests to place of service coding and beyond.

What the Work Plan is: 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. Typically, the OIG releases the document in the fall, but this year the Work Plan was significantly delayed due to “fiscal challenges.” However, the document finally went up on the OIG’s website on Jan. 31, and we’ve got the highlights of what the agency will be targeting this year.

1. Check Out These Diagnostic Radiology Potential Minefields

According to the 2014 Work Plan, the OIG will be looking at the medical necessity of high-cost tests. They don’t identify which tests they think are high cost, but you can assume they will look at CTs, MRIs, 3D, and PET scans. The Work Plan states:

“Billing and Payments. We will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which utilization has increased for these tests. Medicare will not pay for items or services that are not ‘reasonable and necessary.’ (Social Security Act, § 1862 (a)(1)(A).) (OAS; W-00-12-35454; W-00-13-35454; various reviews; expected issue date: FY 2015; work in progress).”

How to Button Up: Make sure your ob-gyn claims featuring diagnostic radiology services show medical necessary with supporting documentation and diagnoses. 

Ob-gyns are using 3D scans, which are becoming a useful diagnostic tool, more frequently. They use them for things such as the evaluation of tumors to differentiate between them being benign or malignant and to observe details of fetal anomalies, says Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.  

However, Medicare has stated CPT® codes 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation) and 76377 (…requiring image postprocessing on an independent workstation) may be considered medically unnecessary and denied if: 

a) equivalent information to that obtained from the test has already been provided by another procedure (magnetic resonance imaging, ultrasound, angiography, etc.) or 

b) equivalent information could be provided by a standard CT scan (two-dimensional) without reconstruction. 

Therefore, it will be crucial that the referring physician provides a written request indicating the clinical need for the additional 3-D imaging, and the interpreting physician maintains a copy of that request. The interpreting physician’s report must address the specific clinical issues that required the 3D modality.

2. Dodge These Electrodiagnostic Testing Mistakes 

Does your urogynecologist report 51785 (Needle electromyography studies [EMG] of anal or urethral sphincter, any technique)? If so you may want to review the following OIG Work plan item for questionable billing of electrodiagnostic testing:

“Billing and Payments. We will review Medicare claims data to identify questionable billing for electrodiagnostic testing and determine the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services. Context—Electrodiagnostic testing, which assists in the diagnosis and treatment of nerve or muscle damage, includes the needle electromyogram and the nerve conduction test. Coverage for diagnostic testing is provided by the Social Security act, § 1861(s)(2), and 42 CFR § 410.32.) The use of electrodiagnostic testing for inappropriate financial gain could pose a growing vulnerability to Medicare. (OEI; 04-12-00420; expected issue date: FY 2013; work in progress).”

How to Button Up: Medicare’s coverage rules are fairly clear with regard to reporting code 51785 and by following them, you can avoid questionable billing, Witt says. EMG of the anal or urethral sphincter (51785) is a diagnostic test that measures muscle activity and that is used to assist in evaluating fecal or urinary incontinence, dysfunctional elimination of bowel and bladder and neurogenic bladder dysfunction leading to functional abnormalities of the muscular sphincter.

Medicare covers EMG studies of the anal or urethral sphincter only for conditions of fecal or urinary incontinence where it is clinically necessary to rule-in or rule-out diagnoses of stress or urge incontinence, mechanical or functional incontinence, or other forms of incontinence. A test is clinically necessary when there is appropriate evaluation and justification prior to the test and when the test is also likely to affect the course of therapy. Medicare would expect to see 51785 billed during the initial diagnostic evaluation only when: 

a) the cause of the fecal incontinence or urinary incontinence cannot be determined from the physician’s evaluation and
b) the physician has determined that diagnostic testing is needed to make a diagnosis.

3. Evaluate How to Make Your E/M Services Iron Clad

Make sure you’re not upcoding your E/M services or cloning records. The OIG is out to discover inappropriate payments for E/M services. They state: 

“Billing and Payments. We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities. Context—Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the billing code for the service on the basis of the content of the service and to have documentation to support the level of service reported. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2014; work in progress).”

How to Button up: To ensure that you aren’t vulnerable to this target area, confirm that your ob-gyns are only documenting the necessary elements in each E/M note, and that each note is based specifically on that patient encounter and the medical necessity required of the visit.

Although this is true of any type of documentation, the problem of cloned notes has become a bigger issue thanks to the use of electronic medical records (EMRs), in which the capability of “carry over,” repetitive “fill ins,” and cloning has become prevalent, experts say.

Remind your providers — and coding/billing staff — that only medically necessary information is considered when you are deciding on the code to bill based on supporting documentation. 

Copy and paste, cloning, and the act of carrying information forward from another record or another portion of the record has the same effect on the integrity of the medical record. Eventually, there will be contradictions in a patient’s record. Payers obviously frown on this type of documentation.

Example: First Coast Service Options, the MAC in Florida, warned providers that “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.”

First Coast further states that discovery of this type of documentation will “result in denial of services for lack of medical necessity and recoupment of all overpayments made.”

Bottom line: Make sure your documentation is unique to each patient and his or her diagnosis.

4. Implement This Imaging Services Advice

The OIG will be using this work plan item to find out if Medicare is paying too much for imaging services and whether they are overused. They say:

“Billing and Payments. We will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. Context—Practice expenses are those such as office rent, wages, and equipment. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expenses. (Social Security Act, § 1848(c)(1)(B).) (OAS; W-00-12-35219; W-00-13-35219; various reviews; expected issue date: FY 2014; work in progress).”

How to Button Up: Review your payments for practice expenses. “Basically, make sure your practice expenses for your ultrasound procedures are in line with your costs.  Heavy mark-ups will be viewed unfavorably by the OIG,” Witt says. 

Also, make sure that each ultrasound that is ordered for a Medicare patient is supported by a clinical indication that will support improved outcomes or treatment for the patient. Ultrasounds performed for “nice to know” reasons would be viewed in a negative light, Witt warns.

5. Launch These Laboratory Test Inquiries

The OIG will be examining the billing characteristics and questionable billing of laboratory tests. The Work Plan states:

Billing and Payments. We will review billing characteristics for Part B clinical laboratory (lab) tests and identify questionable billing. Context—Medicare is the largest payer of clinical lab services in the Nation. Medicare’s payments for lab services in 2008 represented an increase of 92 percent over payments in 1998. In 2010, Medicare paid about $8.2 billion for lab tests, accounting for 3 percent of all Medicare Part B payments. Much of the growth in lab spending has resulted from the increased volume of ordered services. Part B covers most lab tests and pays 100 percent of allowable charges; Medicare beneficiaries do not pay copayments or deductibles for lab tests. Medicare should pay only for those lab tests that are ordered by a physician or qualified nonphysician practitioner who is treating a beneficiary. (42 CFR § 410.32(a). (OEI; 03-11-00730; expected issue date: FY 2013; work in progress)

How to Button Up: The issue here is asking, what constitutes a medically indicated test?  Providers who order a set battery of tests when one would have done may find themselves under scrutiny. They will also likely not want to pay for a test an ob-gyn orders when any abnormal results would not be treated by the physician who ordered the test.  For instance, if an ob-gyn orders a follow-up cholesterol test on his patient during a visit but is not the physician who is actually treating the high cholesterol, Medicare would say the ob-gyn incorrectly billed this test.

6. Fix This Physician and Supplier Problem Area 

The OIG will be looking at noncompliance with assignment rules and excessive billing of beneficiaries:

“Billing and Payments. We will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. We will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries’ share of charges). Context—Physicians participating in Medicare agree to accept payment on ‘assignment’ for all items and services furnished to individuals enrolled in Medicare. (Social Security Act, § 1842(h)(1).) CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or other supplier. The physician or other supplier in return agrees to accept the Medicare-allowed amount indicated by the carrier as the full charge for the items or services provided. (OEI; 07-12-00570; expected issue date: FY 2014; work in progress).”

How to Button Up: When billing Medicare, make sure you know the allowable for each service you charge and that you do not bill the Medicare patient more than the explanation of benefits (EOB) allows after payment. If you are not participating, it will be especially important that you ensure you are not exceeding the limiting charge.  All ob-gyn practices should have at least one person in billing monitoring this, Witt says.

7. Be Proactive About Avoiding POS Errors

Watch out for those place-of-service (POS) coding errors, because the OIG will be shining a spotlight on this issue:

“Billing and Payments. We will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Context— Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors. Federal regulations provide for different levels of payments to physicians depending on where services are performed. (42 CFR § 414.32.) Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center. (OAS; W-00-11-35113; various reviews; expected issue date: FY 2014; work in progress).”

How to Button up: If you perform services in an outpatient hospital setting, you should use place of service 22 instead of 11. If the service took place in an ASC, you should instead use POS code 24. Also, you should realize that if the technical portion of an ultrasound is not performed in the office setting, the interpretation by the physician—even if done in the office setting — must have the POS code for where it was actually performed.

Remember: Even if your physician performs 80 percent of his procedures in the hospital, it’s possible that a gynecological procedure here or an obstetric visit there will take place in the office, so you can never assume that you know the POS when you read a chart. Therefore, you should always be sure to confirm where a procedure was performed before you file the claim with the POS code. 

8. Pick Apart Payments For Outpatient Drugs and Administration of the Drugs 

If your physician is one who specializes in gynecological oncology, then you should note this particular item of the 2014 OIG Work Plan:

“Billing and Payments. We will review Medicare outpatient payments to providers for certain drugs (e.g., chemotherapy drugs) and the administration of the drugs to determine whether Medicare overpaid providers because of incorrect coding or overbilling of units. Context—Prior OIG reviews have identified certain drugs, particularly chemotherapy drugs, as vulnerable to incorrect coding. Providers must bill accurately and completely for services provided. (CMS’s Claims Processing Manual, Pub. No. 100-04, ch. 1, §§ 70.2.3.1 and 80.3.2.2.) Further, providers must report units of service as the number of times that a service or procedure was performed. (Chapter 5, § 20.2, and ch. 26, § 10.4.) (OAS; W-00-12-35576; various reviews; expected issue date: FY 2014; work in progress).”

How to Button Up: Following CPT® guidelines for the administration of chemotherapy will help to avoid incorrect billing, Witt says. Medicare has published their rules in the Claims Processing Manual (100-04, Chapter 12, Section 30.5). You should also consult local carrier as to which drugs may be considered to be chemotherapy drugs under Medicare and how to correctly report the units for these drugs.