Orthopedic Coding Alert

Agency combed everything from injections to consulting agreements.

The Office of the Inspector General (OIG), in its semiannual report to Congress issued on Dec. 3, 2008, reports it recovered more than $20 billion in fiscal year 2008 -- much of which reflects dollars recouped from physicians who billed improperly.

The report lists several audit and investigation highlights that allowed the OIG to recover such huge amounts of money. Among the many surprises that may impact your practice, the OIG found that 63 percent of facet joint injection claims, for instance, did not meet program requirements, for a total of $96 million in Medicare overpayments to physicians.

"I-m not surprised by this, because there's a lot of confusion in the coding community regarding reporting these services," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, compliance specialist at Proliance Orthopedics and Sports Medicine in Bellevue, Wash.

The top errors that the OIG found in this category -- documentation errors and billing add-on codes for bilateral injections -- are unfortunately fairly common among doctors who provide these types of injections, says Randall Karpf with East Billing in East Hartford, Conn. You can be certain these are areas the OIG will be watching very closely in the future.

Example: If your orthopedist performs facet joint injections at the right and left side of the same spinal level -- the right C5-C6 and left C5-C6 in the example -- report 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) with a single unit of service with modifier 50 (Bilateral procedure) appended for bilateral injections.

Warning: Be careful you don't exceed your carrier's utilization guidelines. You should not report the bilateral facet joint injections as one unit of the first or single level code (64470), and one unit of the add-on code (+64472, - cervical or thoracic, each additional level), for "each additional level." This would incorrectly report the orthopedist's bilateral facet joint injections.

The OIG further reports that Medicare overpaid approximately $1.5 million to physicians in two states over a two-year period due to incorrect place of service coding. The OIG found that 85 percent of the sampled services were coded as having been performed in physicians- offices, even though they were actually performed in ASCs or outpatient hospital departments.

The report also lists several criminal and civil actions that the OIG took last year. For example, a healthcare consulting firm in New Jersey paid $2.8 million to resolve allegations that the consultants artificially inflated a hospital's cost-to-charge ratios. This had the effect of triggering excessive outlier payments.

Good advice: "Review the OIG reports frequently as well as the annual OIG work plans," Stumpf recommends. "I use this information to audit and review risk areas in my own practice and base the hierarchy of items in my annual training/auditing plan. It's a tremendous benefit to providers that these findings are so freely shared by the OIG."

To read the report in its entirety, visit the OIG Web site at www.oig.hhs.gov/publications/docs/semiannual/2008/semiannual_fall2008.pdf.