Otolaryngology Coding Alert

Check your compliance on the areas in the 2012 Work Plan before OIG does.

Every practice knows that with payer audits and recoupment requests coming in, now is the time to step up your compliance but where do you start? The HHS Office of Inspector General (OIG)'s 2012 Work Plan, released on Oct. 5 can point you in the right direction.

The OIG has some big plans next year for reviewing Part B claims, and they span the whole spectrum of issues, according to the OIG. Get to know these hot buttons with this rundown.

Review Incident-to Billing Requirements

The OIG intends to determine whether payment for incident to services showed a higher error rate than non-incident to services. "Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record," the Work Plan notes. "They may also be vulnerable to overutilization and expose Medicare beneficiaries to care that does not meet professional standards of quality."

Best practice: Don't bill incident to -- in the name and NPI number of the physician -- unless you are sure you've met the requirements. To qualify for incident to, the physician must have seen the Medicare patient during a prior visit and established a clear plan of care. If the non-physician practitioner (NPP) is treating a new problem for the patient, or if the physician has not established a care plan for the patient, then you cannot report the visit incident to and must bill the service under the NPP's own NPI number.

In addition, when meeting the requirements for a follow-up to an established plan of care, if the physician does not directly supervise the NPP, the incident-to rules do not apply. Direct supervision means a supervising physician must be immediately available in the office suite. The supervising physician, however, does not necessarily need to be the same physician who established the patient's care plan.

Watch out: The NPI used must be the NPI of the physician present in the office suite and supervising the NPP. Submission of the incident to services under the physician's NPI who created the plan of care, but is not directly supervising the care (not present in the suite), even though there is another physician present in the office, is still a violation of the incident to regulations.

Pay Attention to Assignment Rules

When a physician accepts assignment with Medicare, he agrees to accept the Medicare-allowed amount from the carrier as the full charge for the service provided. In 2012, the OIG plans to review "to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare."

Best practice: Confirm with your billing department or contractor that you aren't inappropriately billing any excess patient balances to the beneficiary.

Review Your E/M Coding Practices

The OIG indicates in its Work Plan that it intends to review E/M claims to identify trends between 2000 and 2009, and to determine which providers "exhibited questionable billing for E/M services in 2009."

In addition, the OIG will review the number of E/M services that physicians provided during global surgery periods, and will review claims for which physicians appended a modifier so they could separately collect for E/M visits during the global period.

Rule of thumb: Don't bill separately for E/M-related services relating to the original surgery during the global period. The global surgical package includes routine postoperative care during the global period. You should only append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to an appropriate E/M code when an E/M service occurs during a postoperative global period for reasons unrelated to the original surgical procedure.

For a Medicare patient, you cannot use modifier 24 for services related to complications in the global period, because Medicare does not pay for complications in the global unless they require a return to the operating room. (This is different than defined in AMA CPT).

Stay Up to Date on Hospital Observation Service Coding Rules

The OIG has determined that improper use of observation services "may subject beneficiaries to high cost sharing," and intends to review claims for outpatient observation visits to assess the appropriateness of the services.

Stay on top of CMS's often-changing observation coding rules. For instance, CMS recently clarified how to use subsequent observation care codes 99224-99226 in MLN Matters article MM7405, in which the agency noted that these codes should only be used by the "treating physician." CPT rules allow any physician seeing the patient in an observation setting (not a consultation) to then utilize the subsequent observation codes.

Differentiate 'G' Modifiers Correctly

The OIG intends to review Medicare payments for claims that included the "G" modifiers (GA, GZ, GX, GY) to indicate that a Medicare denial was expected. Often, these modifiers are used in tandem with an advance beneficiary notice (ABN). In the past, the OIG has found that Medicare inappropriately paid millions for services or supplies that should have been denied.

Key: Know the differences between the "G" modifiers with the chart below.

Learn more: To read the OIG's complete Work Plan, visit http://go.usa.gov/93X.