Oncology & Hematology Coding Alert

The department of Health and Human Services Office of Inspector General issued draft guidance, scheduled for publication in June, to help physicians in solo or small group practices avoid fraud and abuse in Medicare and Medicaid programs through voluntary compliance measures.

The policies and procedures that are part of a good compliance program have a direct impact on coding and billing. For example, a well-designed requisition form will help an oncologist identify exactly which service is provided, which in turn tells the coder which code to bill.

Adopting a voluntary compliance program is a lot like practicing preventive medicine; it helps identify and treat small problems before they become big problems, said Inspector General June Gibbs Brown. Strong enforcement and strong voluntary prevention are equally important in safeguarding the government health programs from fraud and abuse. And the cornerstone of our prevention efforts is the development of voluntary compliance guidance that, in partnership with the private sector, will help the healthcare community develop effective compliance programs.

The draft guidance Compliance Program Guidance for Individual and Small Group Physician Practices was scheduled for publication in June as a Federal Register notice and has a 45-day comment period. The Office of the Inspector General plans to publish a final version of the guidance later this year.

We know physicians are busy, but we hope they will take time to review the draft guidance and provide us with thoughtful comments, Brown said. Practicing physicians can offer invaluable insights about how they and their colleagues can put voluntary compliance plans into place in their practices.

Brown says an effective compliance program can help physicians identify both erroneous and fraudulent claims and help ensure that submitted claims are accurate.

Similar to other guidance already issued by the Office of Inspector General for clinical laboratories, hospitals, home health agencies, third-party medical billing companies, durable medical equipment suppliers, hospices, Medicare+Choice plans and nursing facilities, the draft physician guidance is based on the following seven elements:

implementation of written policies and standards of conduct;
designation of a compliance officer or contact;
development of training and education programs;
creation of accessible lines of communication to keep
practice employees updated about compliance activities;
performance of internal audits to monitor compliance;
enforcement of standards through well-publicized
disciplinary directives;
prompt corrective action to detected offenses.

The draft guidance identifies specific compliance risk areas for physicians, such as coding and billing; the provision of reasonable and necessary services; documentation; and improper inducements, kickbacks and self-referrals.

The guidance recognizes that solo and small group physician practices may not have the resources to put a full-fledged compliance program in place and offers suggestions on how a practice can foster a culture that embraces compliance consistent with the size and resources available to the physician practice. For example, instead of operating a confidential hot line to receive complaints, the physician practice might implement a clear open door policy for employees to surface concerns about compliance issues.

The draft guidance also provides direction to larger practices in developing compliance programs by recommending that larger practices use both the physician guidance and previously issued guidance, such as the Third-Party Medical Billing Company Compliance Program Guidance or the Clinical Laboratory Compliance Program Guidance, to create a compliance program that meets the need of the larger practice.