What's New
OIG News: 9 orthopedic compliance alters from the OIG's 2016 Work Plan
1. Non-covered anesthesia services (new). The OIG will review Part B claims for anesthesia services to determine whether they were billed for a patient who actually received a related Medicare service.
2. Payments for personally performed anesthesia services. Anesthesia services performed by anesthesiologists will be reviewed. This isn't a new issue, but a financially significant one because use of modifier "AA" indicates the anesthesiologist personally performed the service and thus full payment is made. Modifier "QK" denotes medically directed anesthesia and reduces payment by 50% of the "AA" modifier amount.
3. Reasonableness of prolonged services (new). The OIG wants to see whether payments for prolonged E/M services were reasonable and met Medicare requirements. Prolonged services are used when E/M services take far longer than typical, at least 30 minutes over the CPT-specified time threshold for the most applicable E/M code. "The necessity of prolonged services are considered to be rare and unusual," the OIG writes in its work plan. Thus your documentation for prolonged services (CPT 99354-99357) needs to demonstrate medical necessity for the extra time, along with time documentation.
4. Orthotic braces (new). This item affects suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) more than orthopaedists, however orthotic braces are a common item. The OIG has evidence that some patients are receiving multiple braces or braces without seeing a physician, or braces without any documentation to support the need for braces. This item will include a carrier-specific review of any carriers that have local coverage determinations (LCDs) requiring more specific documentation for the need of braces.
5. Quality oversight of ASCs (new). The OIG will review how Medicare has been providing oversight of ASCs, specifically state survey agencies that certify ASCs. In some cases more than five years have occurred between certification surveys in some states.
6. Payment for ASCs. The OIG wants to determine whether ASCs are receiving more payment for services than hospital outpatient departments for similar surgical procedures provided in both settings. ASCs received a new payment system in 2008 that was modeled on the Outpatient Prospective Payment System.
7. Part B payments for chiropractic services. Medicare only covers one chiropractic service, which manual manipulation for subluxation of the spine. The OIG will take a look at Part B payments to chiropractors after previous audits found excessive payment to chiropractors as well as "unallowable" payments
in which services other than manipulation were reimbursed. This is a very restrictive coverage guideline because Part B pays only for manipulation if the documentation shows the patient has a neuromusculoskeletal condition for which manipulation is the preferred treatment. Chiropractic maintenance is not considered to be reasonable or necessary and is not covered.
8. Report on Part B payments for chiropractic services. This year, the OIG will actually compile a report on Part B payments for chiropractic services, looking for trends in payment, compliance, and fraud so that it can identify vulnerabilities and offer recommendations to reduce improper payments.
9. High use of outpatient physical therapy services. The OIG will be flagging independent therapists with high utilization of outpatient physical therapy services, looking for medical necessity to support their billing. This is not a new issue, but a perennial one.
Source: Grant Huang, CPC, CPMA (ghuang@drsmgmt.com). The author is Director of Content at DoctorsManagement