Pediatric Coding Alert

The latest Work Plan focuses on several new areas.

This year, you’ll want to make sure you aren’t keeping any Medicaid refunds in your coffers, because the OIG has released its long-awaited 2015 Work Plan -- which includes the agency’s intentions to review Medicaid claims for dozens of services.

What the Work Plan is: The OIG Work Plan details issues that the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General will address during the fiscal year. The agency published its latest document on Oct. 31, which outlines the target areas it will be reviewing in 2015, and we’ve got the highlights below.

Medicaid Overpayments Under Fire

One of the OIG’s 2015 intentions is to evaluate whether practices are keeping Medicaid overpayments rather than sending them back to their state Medicaid programs. “Previous OIG work found Medicaid overpayments in patients’ accounts with credit balances,” the document notes. “Credit balances generally occur when the reimbursement that a provider receives for services provided to a Medicaid beneficiary exceeds the charges billed, such as when a provider receives a duplicate payment for the same service from the Medicaid program or another third party payer.”

Translation: The OIG appears to be looking for incidences where practices bill Medicaid for a specific fee, and then get enough money back from Medicaid to have a surplus in the account. This may happen if you bill a private payer as well as Medicaid, which sometimes results in the private payer sending you money for the whole service, which would make any Medicaid payment qualify as a duplicate or overpayment. “When there is more than one payer, Medicaid is the payer of last resort,” the Work Plan confirms.

How to comply: To ensure that you aren’t vulnerable to this target area, confirm that your practice is sending any overpayments or surpluses back to the Medicaid program rather than simply hanging on to the money or marking it as a credit in the patients’ accounts.

Watch Your Medicaid Pediatric Dental Claims

Another hot spot for the OIG is inappropriate billing for children’s dental services. “Dental services are required for most Medicaid-eligible individuals under age 21 as a component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services benefit,” the Work Plan says. “Services include the treatment of teeth and the associated structure of the oral cavity and disease, injury or impairment that may affect the oral cavity or general health of the recipient.”

Translation: Because many pediatricians perform oral checkups and topical fluoride applications for Medicaid patients, your files could be under scrutiny. This is especially true in light of the fact that CPT® code 99188 (Application of topical fluoride varnish by a physician or other qualified health care professional) is a new code billable as of Jan. 1. Provision of dental services in the pediatric office is growing more common, particularly with Medicaid mandated dental reviews when in-depth dentist’s services are not required.

How to comply: If your practice performs any dental services, be sure to use the appropriate codes, double-check that the patient hasn’t already had a duplicate service performed by a dentist, and keep thorough documentation of the medical necessity for the services.

Encourage Preventive Visits

The OIG will also be reviewing whether children on Medicaid are getting the appropriate preventive visits as covered under the EPSDT services benefit. “Previous OIG work found that, in nine states, three out of four children did not receive all required medical, vision and hearing screenings,” the Work Plan says. The agency is hoping to see more participation in these screenings.

Translation: The government will be looking to determine whether more people utilize the preventive screenings available for children on Medicaid, so if your patients only come in when they have a problem and don’t come in for preventive visits, they could be falling through the cracks of the system.

How to comply: Encourage your Medicaid patients to schedule their annual or semi-annual visits, depending on their ages, and explain to the parents how important the preventive visits are for the patient to get an appropriate number of vaccines, hearing and vision tests, and other preventive services.

Resource: To read the entire 2015 OIG Work Plan, visit http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf.