Primary Care Coding Alert

Documentation:

Find Out if Your Practice Is Triggering OIG Work Plan Audits

Published on Wed Dec 15, 2021

Make sure you avoid these 5 primary care pitfalls.

No one wants to attract unwanted attention and be on the receiving end of an Office of Inspector General’s (OIG) work plan audit. Fortunately, Robin Linker, CHCA, CHCAS, CPC-I, CCS-P, CPC-H, CPC, CPC-P, MCS-P, CHC, CEO of Robin Linker & Associates in Aurora, Colorado, and Susan Garrison, CHCA, CHCAS, CHC, CPC, CCS-P, CPAR, COC, of Med Law Advisors in Dawsonville, Georgia, provided some sage advice about avoiding the audit blues in in their Auditcon Presentation, “Auditing Primary Care Services.”

Here are five common primary care scenarios that can trigger an OIG audit, along with Linker and Garrison’s advice to help avoid the audit blues.

Trigger 1: Avoid E/M Mishaps With Minor Surgery Decisions

Office and outpatient evaluation and management (E/M) services provided on the same day of service as a minor surgical procedure often present problems, especially when a provider has already made the decision to perform a specific minor surgical procedure. Consequently, use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) can often become an OIG audit trigger.

This is especially true for dermatological procedures such as lesion removals, destructions, and biopsies. In 2019, for example, dermatologists themselves incorrectly submitted “claims with an E/M service [that] also included minor surgical procedures … on the same day” about 56 per cent of the time, according to the OIG work plan.

So, it would be incorrect for your primary care provider (PCP) to bill E/M-25 with a lesion removal and biopsy if the only reason for the patient to present is the removal and biopsy on that day of service, Linker and Garrison cautioned.

However, if a patient presents with a suspicious lesion, and the PCP documents a medically appropriate history and/or examination plus medical decision making (MDM) that results in the decision to biopsy or remove the lesion at that encounter, your PCP may appropriately bill an E/M with modifier 25 appended in addition to the appropriate biopsy or removal code.

Trigger 2: Add Detailed Documentation to ACP Services

Advanced care planning (ACP) can also trigger audits if you lack documentation for the time and content of the ACP discussion. The code descriptor for 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate) includes verbiage that the provider must explain and discuss the patient’s advanced directives and that the discussion and explanation must pass the mid-point of the 30 minutes in the descriptor (i.e., be 16 minutes or more). Both must be documented according to Linker and Garrison.

ACP can also create problems as it is reported slightly differently when billed with a sick visit versus a Medicare wellness visit such as the initial preventive physical exam (IPPE) or annual wellness visit (AWV). You’ll still report ACP with 99497 and +99498 (… each additional 30 minutes…). However, when reported in addition to a Medicare wellness visit, you’ll need to bill the ACP with modifier 33 (Preventive services) to bypass patient cost share, since Medicare treats ACP as a preventive service when furnished with a Medicare wellness visit. And though you can report ACP an unlimited number of times, your provider must document medical necessity every time it’s reported separately from a Medicare wellness visit, since Medicare doesn’t consider it preventive then, Linker and Garrison pointed out. (For more information, go to www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf.)

Trigger 3: Take Care to Check TCM Bundling

Payments for transitional care management (TCM) have triggered numerous audits in past years because you could not bill chronic care management (CCM), end-stage renal disease (ESRD) services and prolonged services separately without patient contact prior to 2021. (Remember: The OIG can still perform audits of TCM services performed prior to 2021 using the guidelines pertinent to the date of service, Linker and Garrison noted.)

Even so, you should avoid OIG scrutiny by “verifying what other services were reported during the same period as the TCM services and contrast with CPT^®for potential overlap and noncompliance.” You should also not count TCM “within a postop period of a service you report, and not count patient discharge for the face-to-face component of the TCM services,” Linker and Garrison advised.

Trigger 4: Don’t Just Do CCM — Document It

In November 2019, the OIG reported they had overpaid for CCM to the tune of “hundreds of thousands of dollars.” With CCM firmly on the OIG’s radar, Linker and Garrison stressed the importance of paying attention to the way you document CCM and related services.

“Documentation for CCM, and for AWVs, must include notation in the medical record that care plan documentation has been given to patient and that the patient consents to that plan,” Linker and Garrison noted. Also, any cost sharing with the patient must be documented in order to avoid OIG auditing.

Trigger 5: Time to Change Preventive and E/M-25 Documentation

Another modifier 25 trigger concerns office/outpatient E/M services billed with preventive E/M services. The main guidelines for reporting the two service together have not changed. You still have to justify that a problem is “significant enough to require additional work to perform the key components of a problem-oriented evaluation and management service,” and that still has to be documented with modifier 25 appended to the office/outpatient E/M.

However, preventive services are not time-based codes, while office/outpatient E/Ms may be, so any time spent on the preventive E/M cannot be counted toward the time for the problem-oriented office/outpatient E/M, Linker and Garrison noted. Consequently, per CPT^®Assistant, “the code for the problem-assessment portion of the encounter will likely be selected based on MDM” (February 2021). Additionally, while a different diagnosis is not required when using modifier 25, it is always useful and helps to justify the E/M-25. In the case of a preventive E/M and problem-oriented E/M provided at the same encounter, different diagnosis codes would be expected to reflect the preventive versus problem-oriented nature of the two services.