Pulmonology Coding Alert

The HHS Office of Inspector General has released the work plan for the 2003 fiscal year, and the results from its proposed evaluations may greatly affect your practice in years to come. There are plans to evaluate a wide range of services and procedures that directly impact the way your practice does business:

Evaluate controls that detect excessive Medicare payments to institutional providers for inpatient and outpatient services

Determine the appropriateness of billing for physician consultation services, the financial impact of inaccurate billing, and the reasons for inappropriate billing

Evaluate conditions under which physicians bill "incident-to" services and supplies because it is unknown what types of services are billed and the quality and appropriateness of such billing

Examine whether physicians accurately code E/M services and assess the adequacy of controls that identify physicians with a high volume of codes for high-level E/M services

Determine if beneficiaries received medically necessary allergy treatment in accordance with Medicare requirements

Review documentation for claims that were submitted by physicians for beneficiaries who were located a significant distance from the site of the physician service

Review nonphysician practitioner services to determine the appropriateness of their claims with respect to the services allowed under their scope of practice

Evaluate the appropriateness of payments made for routine healthcare costs surrounding patients participating in clinical trials. Regarding the allergy treatment, a recent study shows that treatment is inappropriate in 12 out of 18 cases. This is based on the length of treatment or the presence of contraindications. Another problem is the inadequacy of documentation or the lack of medical necessity.