Pathology/Lab Coding Alert

The Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) has released its work plan for fiscal year 2001. It includes a listing of the focus areas that the OIG intends to target for investigation in the coming year. Of particular interest to laboratories and pathologists will be the following target areas:

Clinical Laboratory Improvement Amendments (CLIA) Certifications. The OIG will use CLIA certification requirements and Medicare billing records to ensure that labs are in compliance by performing only tests appropriate for their certification level.

Clinical Laboratory Proficiency Testing. The OIG will examine the testing and grading process now in place to ensure laboratory proficiency and accuracy of lab results.

Advance Beneficiary Notices (ABNs). The OIG will investigate ABNs regarding their use and financial impact on beneficiaries and providers. The work plan states, Indications are that practices vary widely regarding when ABNs are provided, especially with respect to noncovered laboratory services.

Cholesterol Testing. The OIG will determine whether cholesterol tests billed to Medicare are medically necessary and accurately coded. This will include an examination of lipid panel tests and frequency of testing.

Hepatitis Tests. The OIG will examine Medicare payments to hospital laboratories for hepatitis tests for dialysis patients. Specifically, they will investigate whether the services are reasonable and necessary at the frequency provided based on the patients immune status and susceptibility to various strains of hepatitis.

Pneumonia Diagnosis Related Group (DRG) Upcoding. Along with the Department of Justice, the OIG will investigate information that hospitals have upcoded the DRG for certain pneumonia claims from viral to bacterial pneumonia, thus obtaining almost $2,500 extra per claim in reimbursement.

The OIG has identified other, more general focus areas for 2001, such as a review of the outpatient prospective payment system and Medicare Part B, which may also impact laboratory compliance and coding. The full text of the more-than-100-page OIG work plan is available on the Department of Health and Human Services Web site at: www.dhhs.gov/progorg/oig/wrkpln/2001/wp2001.pdf.