Orthopedic Coding Alert

Heads up, orthopedic coders: The U.S. Office of Inspector General (OIG) will be scrutinizing your claims for bone density screenings (76075-76078, 76977, 78350-78351), incident-to services, skilled nursing facility (SNF) consolidated billing, and diagnostic tests performed in emergency rooms.

According to its recently released 2003 Work Plan, the OIG will determine whether carriers are making inappropriate bone density screening payments in 2003. Insurers' frequency guidelines for these tests vary, but most Medicare carriers share similar specifications, listed at right.

The OIG will also review whether physicians who treat SNF patients follow CMS' consolidated billing guidelines. (For more on consolidated billing, see our article"Split X-Ray Components for SNF Patients" in the November 2002 issue of Orthopedic Coding Alert.)

The OIG Work Plan indicates that nonphysician practitioner (NPP) billing has increased fourfold since the OIG started watching these claims and that they intend to scrutinize "several potential" NPP billing vulnerabilities in 2003.

The most commonly billed NPP code in orthopedic practices is 99211 (Established patient office or other outpatient visit, that may not require the presence of a physician). Nurses frequently bill this code when checking vital signs, removing simple sutures, reviewing self-medication instructions or for other uncomplicated visits.

Even though the orthopedist is not required to see the patient during the 99211 visit, the physician must be present somewhere in the office at the time.

The Work Plan also states that "questions persist about the quality and appropriateness" of incident-to billings. For more on incident-to billing, see article 2.

The full text of the OIG's Work Plan is available on the HHS Web site at http://oig.hhs.gov/publications/workplan.html.