2017 Compliance Program Key Initiatives
This year’s Compliance Program is built around six areas of concentration outlined by the Office of Inspector General 2017 Work Plan. Improved compliance initiatives and measures will be rolled out over the coming months, but it’s important for you to prepare by learning more about each area of focus. That’s why we’ve put everything you need to know in one place.
- Billing and Coding for Office vs. Ambulatory Surgical Center
OIG wants to see whether services billed under provider-based place of service (POS) codes such as POS 11 for office/outpatient are actually being rendered in free-standing settings, such as ambulatory surgery centers (ASCs). Because provider-based POS codes boost payments by factoring in greater overhead associated with professional services, they pay more for the same CPT codes. This could lend itself to abuse. Make sure your providers use the proper POS code (POS 24) when billing for services in the ASC setting.
- Two-Midnight Rule: Outpatient vs. Inpatient Payment
OIG wants to see whether hospitals are properly following the two-midnight rule implemented by CMS on October 1, 2013, to ensure inpatient and outpatient payments are being made properly. The rule mandates that if physicians predicted patients to stay over “two midnights,” inpatient payment is needed. Comparatively, if patients do not meet this “two midnight” requirement, outpatient payment is appropriate. While hospitals are the chief targets, orthopaedic surgeons who perform admissions should also pay heed to this differentiation.
- Increased Payments for Orthotic Braces
Medicare payments for orthotic braces, including back and knee braces, have more than doubled since 2009; some types of knee braces have seen their payments triple during the same time period. OIG will take aggressive action to determine whether these payment increases are substantiated.
OIG will compare Medicare payments to those of private insurers to assess the scope of any possible wasteful spending on orthotic braces.
- Medical Necessity of Orthotics
OIG’s audit explicitly calls for the review of Part B payments for orthotic braces in order to prove documentation supports the medical necessity.
The OIG believes that some DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) suppliers bill for unnecessary services, including cases where patients receive multiple braces and where patients who were not seen by referring physicians were billed for braces.
- Medical Necessity of Prolonged Services
When an E/M (evaluation and management) service far exceeds the typical visit time associated with the level of service, prolonged service CPT codes (99354-99357) may be billed with proper documentation. The OIG will review claims regarding prolonged service codes to ensure that the services are medically necessary and that documentation requirements (including face time with patients) are met.
- Medicare Part B Payment for Chiropractor Services
Medicare Part B only pays for chiropractic manual manipulation of the spine to correct subluxation if there is a neuro-musculoskeletal condition being covered. Chiropractic maintenance therapy is not covered because CMS has determined it does not meet medical necessity. In some cases, the OIG believes maintenance therapy is occurring in some cases where chiropractic manipulation is being billed. OIG inspectors will review claims to ensure compliance with the above policy.