Medicare Hospital Compliance Reviews are Legal and Sound, According to OIG

The Office of Inspector General for the Department of Health and Human Services (OIG) recently defended its practices pertaining to hospital compliance reviews in a published response to a letter from the American Hospital Association (AHA), while simultaneously announcing a voluntary suspension of reviews of inpatient short stay claims after October 1, 2013.

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Fiscal Year 2012 HHS OIG Work Plan

The HHS Office of Inspector General (OIG) Work Plan for Fiscal Year 2012 provides brief descriptions of activities that OIG plans to initiate or continue with respect to HHS programs and operations in fiscal year 2012.

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Overcome 3 Myths and Claim Reimbursement Opportunities using Modifier 22

Don’t fall for these common body habitus, time, and fee traps.

If you overuse Modifièr 22 (Increased procedural services), you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifièr entirely, you’re likely missing out on reimbursement your cardiologist deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the normal effort of services described by a particular CPT® codè — and no other CPT® codè better describes the work involved in the procedure — you should look to modifièr 22. Modifièr 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT® codè but do land outside the norm and may support added reimbursement for a given procedure.  Take a look at these three myths — and the realities — to ensure you don’t fall victim to these modifièr 22 trouble spots.

Myth 1: Morbid Obesity Means Automatic 22

Sometimes, an interventional cardiologist may need to spend more time than usual positioning a morbidly obese patient for a procedure and accèssing the vessels involved in that procedure. In that case, it may be appropriate to append modifièr 22 to the relevant surgical codè. However, it’s not appropriate to assume that just because the patient is morbidly obese you can always append modifièr 22.  “Modifièr 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, Manager of Compliance education for the University of Washington Physiciáns Compliance Program in Seattle.

“Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifièr 22 should not be appended,” warns Maggie Mac, CPC,...

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Look Good in Orange?

Billing Expert Offers Tips for Avoiding Fraud Charges

by Michael Vlessides

San Diego—Few physicians ever seriously consider the possibility of becoming formally acquainted with the Office of Inspector General or the FBI. -memberlock Login to Read More

CPC Exam Study Guide
CCA Exam Study Guide
CCS Exam Study Guide
CPB Exam Study Guide
CRC Exam Study Guide

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Coding Compliance: OIG Targets Transforaminal Epidural Injections

Verify that you’re counting injections and levels correctly to keep claims clean. The Office of Inspector General (OIG) Work Plan for 2010 includes a closer look at Medicare payments for transforaminal epidural injections. The Work Plan specifically states, “We will review Medicare claims to determine the appropriateness of Medicare Part B payments for transforaminal epidural injections.” Stay [...] Related articles:

  1. Save Time Coding Facet Injections With This Coding Tool Hint: Location, number and substance are key. Several factors...
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  3. Trigger Point Injection Coding: Count Targets, Not Shots Become the top TPI gun in your coding department...

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Medicare’s Consult Rule Trickle Down Effect

And what it means for pediatric practices. A report from AMA in Chicago. Although CPT clarifies the transfer of care definition, the fix came too late for Medicare, meaning your private payers may follow suit. Continued Errors Result in E/M Boon The Office of Inspector General found a high error rate on consultation codes. Different opinions on when [...] Related articles:

  1. Medicare 2010 CPT Consultation Code ChangesNew rules for consult coding straight from the AMA Meeting...
  2. CMS at AMA Chicago: We’re Reducing Consult Request RequirementCMS auditors will look for 1 less thing in consult...
  3. AMA Symposium Report: Low-Level Consult Reporting in 2010 Hey, Coding News readers! It’s your turn to weigh...

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Nonphysician Providers and Incident-To: Your Coding Questions Answered

Here’s why you should keep your physicians’ work schedules on file. Correctly billing your nonphysician practitioners (NPPs) incident-to services means the difference between 85 and 100 percent reimbursement. But if you bill incident-to haphazardly, you’re just waving a red flag at auditors. And those auditors are jonesin’ to find incident to billing problems. Just check out this [...] Related articles:

  1. Nonphysician Providers & Incident To ChecklistCheck state laws PLUS this crucial document. In last week’s...
  2. Steer Your Incident-To Coding Using These 4 Questions 100 percent pay possible if NPP follows internist’s care...
  3. Use This Incident-To Checklist to Breathe Easy During an Audit You don’t need to second-guess the way you bill...

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Radiology Billing Checklist: Rules for Additional Tests without Treating Physician’s Order

Keep these additional test rules at your fingertips if your want to keep auditors out of your hair. The Office of Inspector General and Recovery Audit Contractors are out to audit non-compliant ultrasound claims, so knowing the rules is more important than ever. And we’ve got a link and a handy checklist to keep you out [...] Related articles:

  1. OIG Slaps Radiology Practice With Record $2 Million PenaltyThink it’s okay to provide diagnostic tests without physician orders?...
  2. Documentation Checklist for Complex Radiology Treatment Planning (77263) Think you know all you need to know about...
  3. 3 Big Fee Schedule Changes for Radiology Coding & BillingCapture additional $2,305 for Bilateral 50593 by Applying Fee Schedule...

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A Physician Coder’s Guide to the 2010 OIG Work Plan

If your practice does lab panels, sleep studies, hospice visits and more, take heed. The HHS Office of Inspector General has published its 2010 Work Plan, which should give us all a heads up on what the watchdog agency will be auditing and evaluating this year. Why you should care: The 115-page document is like a map [...] Related articles:

  1. Proposed 2010 Physician Fee Schedule: A Closer Look21.5 percent cut looms for your services Last week, Coding...
  2. New PQRI, E-Prescribe Tool from CMS If your head is spinning with all of the...
  3. How Obama’s Medicare Cuts Hit Physician Reimbursement  The budget released Thursday suggests we cut $300 billion from...

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