Transcript Document

Coding and Billing Update
IOA 117th Annual Convention
May 3, 2014
Presented by
Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
5725 Park Plaza Court
Indianapolis, IN 46220
Voice: 317.573.3960
Fax: 866-631-9310
E-mail: [email protected]
This presentation was current at the time it was published and is intended to
provide useful information in regard to the subject matter covered.
Newby Consulting, Inc. believes the information is as authoritative and accurate
as is reasonably possible and that the sources of information used in preparation
of the manual are reliable, but no assurance or warranty of completeness or
accuracy is intended or given, and all warranties of any type are disclaimed.
The information contained in this presentation is a general summary that explains
certain aspects of the Medicare Program, but is not a legal document. The official
Medicare Program provisions are contained in the relevant laws, regulations, and
rulings.
Any five-digit numeric Physician's Current Procedural Terminology, Fourth
Edition (CPT) codes service descriptions, instructions, and/or guidelines are
copyright 2013 (or such other date of publication of CPT as defined in the federal
copyright laws) American Medical Association.
For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes
and service/procedure descriptions to be used in this presentation.
The American Medical Association assumes no responsibility for the
consequences attributable to or related to any use or interpretation of any
information or views contained in or not contained in this publication.
Update 2014 Medicare Fee Schedule
Pathway for SGR Reform Act of 2013 §1101 –
Medicare Physician Payment Update
– Replaced the 20.1% with a 0.5% update
• Only for dates service 1/1/2014 – 3/31/2014
• Original update kicks in 4/1/2014
Protecting Access to Medicare Act of 2014
– Continues 1st quarter fee schedule through
3/31/2015
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Sequestration
Budget Control Act of 2011
– Requires 2% payment cut for all Medicare
physician claims
– Dates of service on or after April 1, 2013
Pathway for SGR Reform Act of 2013 extended
the 2% cut in Medicare payments from
sequestration until 2023
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Place of Service Codes
Location where the service is rendered
– Exception - for a service rendered to a patient who
is a registered inpatient or an outpatient of a
hospital:
• In these cases, the correct POS code - regardless of
where the face-to-face service occurs - is the
appropriate inpatient POS code (at a minimum POS
code 21) or the appropriate outpatient hospital POS
code (at a minimum POS code 22)
• E/M services must be reported using hospital
inpatient, hospital observation, or office/other
outpatient CPT codes
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POS – Cont’d
Example, when a hospital inpatient is seen in the
physician’s office the POS code must be “21”
inpatient hospital
– Use Inpatient E/M codes
– Item 32 of the claim must reflect the address and ZIP
code where the patient was seen for the face-to-face
service ( in this example, the physician’s office)
– Remember, when billing POS 21, Medicare only pays
for professional services
– Charges for nonprofessional services are included in the
hospital’s DRG payment
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POS – Cont’d
This rule is also applicable when a patient seen in the
office setting is an inpatient in a skilled nursing
facility (SNF) and is in a Part A covered stay
– Report POS 31 skilled nursing facility
– Use nursing facility E/M codes to report visits
– Follow all other SNF Consolidated Billing instructions
• Bill all professional services to the MAC
• Bill all Medicare-covered non-professional services
to the SNF
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Date of Service
Many diagnostic services have two components; a
technical and professional component
– The date of service submitted to Medicare for the
technical component is the date the technical
component is performed
– The date of service submitted to Medicare for the
professional component is the date the professional
component is performed
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Date of Service Cont’d
When the technical and professional components of a
radiology service are performed on different days, the
services are not global and should be separated into
their separate parts and each component should reflect
the actual date performed
– For example, the test should be split into two line items
when the technical component is performed on
Tuesday, January 8, 2014 and the professional is
performed on Wednesday, January 9, 2014
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Skilled Nursing Facility – Part A
Covered Stay – Original Medicare
Consolidated billing applies
– Bill Medicare for all professional services
– Bill SNF for nonprofessional services, e.g., technical
component of tests, “J” codes for injectable drugs,
covered DME, etc.
This rule is also applicable when a patient seen in the
office setting is an inpatient in a skilled nursing
facility and is in a Part A covered stay.
– Report POS 31 skilled nursing facility
– Use nursing facility E/M codes to report visits
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Complying with Coding and Billing
Procedures and Documentation Guidelines
Medicare contractors are required to implement
aggressive efforts to lower claims error rates by
developing plans that address the cause of the
errors and outline efforts for correction of these
issues
The Comprehensive Error Rate Testing Contractor
identified the top 20 service types with highest
improper payment rates in Appendix B of the
Medicare Fee-for-Service 2013 Improper Payment
Rate Report
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Definitions Used in the Report
No Documentation
– Claims are placed into this category when either
the provider or supplier fails to respond to repeated
requests for the medical records or the provider or
supplier responds that they do not have the
requested documentation
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Definitions Used in the Report
Cont’d
Insufficient Documentation Errors
– Claims are placed into this category when the medical
documentation submitted is inadequate to support payment
for the services billed
• In other words, the reviewers at the CERT contractor could not
conclude that some of the allowed services were actually
provided, were provided at the level billed, and/or were
medically necessary
– Claims are also placed into this category when a specific
documentation element that is required as a condition of
payment is missing, such as a physician signature on an
order, or a form that is required to be completed in its
entirety
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Definitions Used in the Report
Cont’d
Medical Necessity Errors
– Claims are placed into this category when the
reviewers at the CERT contractor receive adequate
documentation from the medical records submitted
to make an informed decision that the services
billed were not medically necessary based upon
Medicare coverage policies
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Definitions Used in the Report
Cont’d
Incorrect Coding Errors
– Claims are placed into this category when the
provider or supplier submits medical
documentation supporting
• a different code than that billed
• that the service was performed by someone other
than the billing provider or supplier
• that the billed service was unbundled
• that a beneficiary was discharged to a site other than
the one coded on a claim
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CERT Report
Office Visit New Patient
– Improper payment – 18.9%
•
•
•
•
No documentation – 0.0%
Insufficient documentation – 15.1%
Medical Necessity – 0.6%
Incorrect Coding – 84.3%
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CERT Report
Office Visit Established Patient
– Improper payment – 7.1%
•
•
•
•
No documentation – 3.1%
Insufficient documentation – 48.4%
Medical Necessity – 0.4%
Incorrect Coding – 48.1%
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CERT Report
Initial Hospital Visit
– Improper payment – 28.3%
•
•
•
•
No documentation – 2.0%
Insufficient documentation – 21.7%
Medical Necessity – 0.0%
Incorrect Coding – 75.9%
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CERT Report
Hospital Visit - Subsequent
– Improper payment - 18.2%
•
•
•
•
No documentation – 4.6%
Insufficient documentation – 57.6%
Medical Necessity – 0.0%
Incorrect Coding – 37.2%
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CERT Report
Critical Care
– Improper payment – 22.9%
•
•
•
•
No documentation – 3.2%
Insufficient documentation – 49.2%
Medical Necessity – 0.0%
Incorrect Coding – 47.6%
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CERT Report
Nursing Home Visit
– Improper payment – 13.9%
•
•
•
•
No documentation – 5.4%
Insufficient documentation – 39.1%
Medical Necessity – 0.0%
Incorrect Coding – 52.7%
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CERT Report
Emergency Department Visit
– Improper payment – 11.6%
•
•
•
•
No documentation – 0.0%
Insufficient documentation – 18.2%
Medical Necessity – 0.0%
Incorrect Coding – 81.8%
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CERT Report
Musculoskeletal X-rays
– Improper payment – 15.0%
•
•
•
•
No documentation – 4.3%
Insufficient documentation – 65.5%
Medical Necessity – 3.6%
Incorrect Coding – 25.7%
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CERT Report
Improper payment By Specialty (Not All Inclusive)
– Internal Medicine – 15.3%
– Family Practice – 13.7%
– Nurse Practitioner – 7.7%
– Physician Assistant – 12.1%
– Cardiology – 11.8%
– Pulmonary – 18.1%
– Emergency Medicine – 10.9%
– Orthopaedic Surgery – 10.0%
– Psychiatry – 22.1%
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Documentation Timeliness
Physicians/practitioners may not submit a claim
to Medicare until the documentation is completed
– This means the claim should not be submitted until
the physician/practitioner completes the
documentation for a service, including signature
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Documentation Timeliness Cont’d
Physician/practitioners are expected to complete
the documentation of services "during or as soon
as practicable after it is provided in order to
maintain an accurate medical record”
– WPS interpretation “no more than a couple of days
away from the service itself”
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Documentation Policies and
Procedures
American Health Information Management
Association (AHIMA)
– Once the signature is applied the entry is
considered complete and the record should be
locked to prevent editing including deleting and/or
making changes including additions to the medical
record (e.g., progress note, operative report, test
interpretation)
– The only opportunity to make changes should be
through an amendment or addendum to that entry
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Addendums
Ensure the addendum is appended to each report
in the same manner (e.g., at the top of the related
document)
– The addendum should be clearly labeled
– The addendum should include a new signature line
that the provider must sign in addition to the
signature on the original document
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Addendums Cont’d
Organizations should have clearly defined
policies, procedures, and practices to ensure that
the integrity of the health information remains
intact, regardless of how and when information is
clarified
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CMS Documentation Warning!
There are those that believe the more you document,
the higher the level of care that can be chosen to
describe the service rendered to the patient
Medicare Claims Processing Manual Chapter 12
§30.6.1A – Not all-inclusive
– Medical necessity of a service is the overarching criterion
for payment in addition to the individual requirements of a
CPT code. It would not be medically necessary or
appropriate to bill a higher level of evaluation and
management service when a lower level of service is
warranted
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CMS Documentation Warning Cont’d
The volume of documentation should not be the
primary influence upon which a specific level of service
is billed. Documentation should support the level of
service submitted. The service should be documented
during, or as soon as practicable after it is provided in
order to maintain an accurate medical record. [Emphasis
Added]
Remember WPS timeliness standard “no more than a
couple of days”
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Review Findings EHR Progress Notes
During repeated reviews, Medicare Contractors
have observed the tendency to "over-document"
and consequently to select and bill for a higher
level E/M code than medically reasonable and
necessary
– Word processing software, the electronic medical
record, and formatted note systems facilitate the
"carry over" and repetitive "fill in" of stored
information
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Over Documentation
Even if a "complete" note is generated, only the
medically reasonable and necessary services for
the condition of the particular patient at the time
of the encounter as documented can be considered
when selecting the appropriate level of an E/M
service
Information that has no pertinence to the patient's
situation at that specific time cannot be counted
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CMS Documentation Tips
Providers should be aware that templates designed
to gather selected information focused primarily
for reimbursement purposes are often insufficient
to demonstrate that all coverage and coding
requirements are met
– Beware of templates that overestimate decisionmaking. Understand the logic of templates and/or
computer programs used for E/M service coding
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Correct Use of Checklists and Templates
in E/M Documentation
Physicians and non-physician practitioners may use
templates, checklists, and/or electronic medical
records to assist in documenting services and saving
time
– WPS considers these formats acceptable documentation
• Caveat, the documentation submitted must be specific to
the patient and the service in question
– Appropriate to evaluate the patient’s presenting
problem, problems described in the HPI and ROS
– Exam findings
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OIG Report – January 2014
Tracing authorship and documentation in an EHR
may not be as straightforward as tracing in a paper
record
Health care providers can use EHR software
features that may mask true authorship of the
medical record and distort information in the
record to inflate health care claims
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OIG Report – Copy-Pasting
Copy-pasting, also known as cloning, enables users to
select information from one source and replicate it in
another location.
– When doctors, nurses, or other clinicians copy-paste
information but fail to update it or ensure accuracy,
inaccurate information may enter the patient’s medical
record and inappropriate charges may be billed to
patients and third-party health care payers
– Inappropriate copy-pasting could facilitate attempts to
inflate claims and duplicate or create fraudulent claims
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OIG Over-Documentation
Over-documentation is the practice of inserting false or
irrelevant documentation to create the appearance of
support for billing higher level services.
– Some EHR technologies auto-populate fields when using templates
built into the system.
– Other systems generate extensive documentation on the basis of a
single click of a checkbox, which if not appropriately edited by the
provider may be inaccurate.
– Such features can produce information suggesting the practitioner
performed more comprehensive services than were actually
rendered.
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OIG Findings
Although EHR technology may make it easier to
perpetrate fraud, CMS and its contractors have not
adjusted their practices for identifying and
investigating fraud in EHRs
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OIG Recommendations
CMS should provide guidance to its contractors on
detecting fraud associated with EHRs
CMS should direct its contractors to use
providers’ audit logs
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New Supplemental Medical Review
Contractor
StrategicHealthSolutions, LLC
– Performs and/or provides support for a variety of
tasks aimed at lowering the improper payment rates
and increasing efficiencies of the medical review
functions of the Medicare and Medicaid programs.
– Primary tasks will be conducting nationwide
medical reviews as directed by CMS.
• CMS assigns each project through Technical
Direction Letters (TDL)
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New Supplemental Medical Review
Contractor - TDLs
Project Y1P2 – Evaluation and Management
(E/M) Services
– This TDL was a result of an OIG report OEI-04-1000180 which has recommendations to review
physicians’ billing for E/M services
• The E/M services provided refer to visits and
consultations furnished by physician and nonphysician practitioners (providers) to assess and
manage beneficiary healthcare
– This TDL is for E/M services billed with CPT codes
99214 and 99215
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Region C RAC - Connolly
Region C - Alabama, Arkansas, Colorado, Florida,
Georgia, Louisiana, Mississippi, New Mexico,
North Carolina, Oklahoma, South Carolina,
Tennessee, Texas, Virginia and West Virginia
Auditing claims that contain higher-level CPT
codes for evaluation and management services focus on claims for 99214 and 99215
– Limited Review - Statistical Sampling on
Evaluation and Management claims to calculate
and project incorrectly paid claims
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E/M Codes
Continue to account for the vast majority of
physician errors
–
–
–
–
Missing chief complaint
Inadequate HPI
Missing assessment and plan
Insufficient documentation for coding by time
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E/M Coding
Problem-oriented E/M
– Based on content
• History
• Exam
• Medical Decision Making
– Based on time
• More than 50% of time spent in
counseling/coordination of care
Time-based codes
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E/M Chief Complaint
The chief complaint is a concise statement describing
the symptom, problem, condition, diagnosis, physician
recommended return, or other factor that is the reason
for the encounter.
Must be documented for every encounter
– Subsequent hospital inpatient
– Subsequent observation
– Subsequent nursing facility
Must be addressed in the assessment AND plan of
care
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E/M Chief Complaint Cont’d
Not acceptable
–
–
–
–
Follow-up
Med Check
Wants to establish
3-mo check up
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E/M History of the Present Illness (HPI)
Physician work
– Must validate the chief complaint
– Must be evident information was obtained and
documented by the physician
• Cannot count/use information obtained and
documented by staff
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History of the Present Illness (HPI)
Cont’d
Symptomatic patients
– Obtain 4 HPI elements
•
•
•
•
•
•
•
•
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs and Symptoms
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E/M History of the Present Illness
Cont’d
Asymptomatic Patients
– Documentation should include information related
to the reason for the encounter, e.g., abnormal test
results, follow-up visit notes patient is compliant
with treatment recommendations
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E/M History - Review of Systems
Review of symptoms
– Not a review of medical problems
• Diabetes
• Hypertension
• Arthritis
Must document all positive findings
Must document pertinent negatives for organ system(s)
related to the chief complaint
Must be evident the information was reviewed by the
physician
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E/M Past History
Prior major illnesses and injuries
Prior operations
Prior hospitalizations
Current medications
Allergies (eg, drug, food)
Age appropriate immunization status
Age appropriate feeding/dietary status
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E/M Family History
The health status or cause of death of parents,
siblings, and children
Specific diseases related to problems identified in
the Chief Complaint or History of the Present
Illness, and/or System Review
Diseases of family members that may be
hereditary or place the patient at risk
– Document who in family has problem
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E/M Social History
Age appropriate review of past and current
activities
–
–
–
–
–
–
–
Marital status and/or living arrangements
Current employment
Occupational history
Use of drugs, alcohol, and tobacco
Level of education
Sexual history
Other relevant social factors
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E/M Examination
Two Guidelines
– 1995
• Performance and documentation of examination
elements for
– Body areas
– Organ systems
– 1997
• Performance and documentation of examination
elements for
– General Multi-System Exam
– Single Organ System Exam
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E/M Documentation Guidelines
The Documentation Guidelines for E/M services
reflect the needs of the typical adult population
For certain groups of patients, the recorded
information may vary slightly from that described
in the guidelines
Although not specifically defined in the
documentation guidelines, variations on history
and examination are appropriate for infants,
children, adolescents and pregnant women
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E/M Documentation Guidelines Cont’d
The medical records of infants, children,
adolescents and pregnant women may have
additional or modified information recorded in
each history and examination area
The content of a pediatric examination will vary
with the age and development of the child
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E/M Documentation Guidelines Cont’d
Newborn example
– The record may include under history of the
present illness (HPI) the details of mother's
pregnancy and the infant's status at birth
– Social history will focus on family structure
– Family history will focus on congenital anomalies
and hereditary disorders in the family
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E/M Exam – General Instructions
Specific abnormal and relevant negative findings
of the examination of the affected or symptomatic
body area(s) or organ system(s) should be
documented
– A brief statement or notation indicating "negative"
or "normal" is sufficient to document normal
findings related to unaffected area(s) or
asymptomatic organ system(s)
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1995 - Body Areas
Head, including the face
Neck
Chest, including breasts and axilla
Abdomen
Genitalia, groin, buttocks
Back
Each extremity
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1995 Organ Systems
Eyes
Ears, nose, mouth, and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
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1995 – 4 Types of Exam
Problem focused: A limited examination of the
affected body area or organ system.
Expanded problem focused: A limited
examination of the affected body area or organ
system and other symptomatic or related organ
system(s) (2-7 body areas/organ systems)
Detailed: An extended examination of the affected
body area(s) and other symptomatic or related
organ system(s) (2-7 body areas/organ systems)
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1995 – 4 Types of Exam Cont’d
Comprehensive: A general multisystem
examination
– The medical record for a general multi-system
examination should include findings about 8 or
more of the 12 organ systems
– Refer to the 1997 guidelines for single organ
system exams
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1997 Examinations
It is possible for a given examination to be
expanded beyond what is defined in the
documentation guidelines.
– When that occurs, findings related to the additional
systems and/or areas should be documented
– Other elements do not “substitute” for defined
elements
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1997 Examinations Cont’d
General multi-system examination
Single organ system examinations
–
–
–
–
–
–
–
–
–
–
–
Cardiovascular
Ears, Nose, Mouth, and Throat
Eyes
Genitourinary (Female)
Genitourinary (Male)
Hematologic/Lymphatic/Immunologic
Musculoskeletal
Neurological
Psychiatric
Respiratory
Skin
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1997 – General Multi-Specialty
4 Types of Examination
Problem Focused Examination – should include
performance and documentation of one to five
elements identified by a bullet (•) in one or more
organ system(s) or body area(s)
Expanded Problem Focused Examination – should
include performance and documentation of at least
six elements identified by a bullet (•) in one or
more organ system(s) or body area(s)
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1997 – General Multi-Specialty
4 Types of Examination Cont’d
Detailed Examination – should include at least six
organ systems or body areas. For each system/area
selected, performance and documentation of at
least two elements identified by a bullet (•) is
expected
– Alternatively, a detailed examination may include
performance and documentation of at least twelve
elements identified by a bullet (•) in two or more
organ systems or body areas
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1997 – General Multi-Specialty
4 Types of Examination Cont’d
Comprehensive Examination – should include at
least nine organ systems or body areas
– For each system/area selected, all elements of the
examination identified by a bullet (•) should be
performed, unless specific directions limit the
content of the examination
– For each area/system, documentation of at least
two elements identified by a bullet is expected
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1997 – Single Organ Systems
4 Types of Examination
Variations among these examinations in the organ
systems and body areas identified in the left
columns and in the elements of the examinations
described in the right columns reflect differing
emphases among specialties
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1997 – Single Organ Systems
4 Types of Examination Cont’d
Problem Focused Examination – should include
performance and documentation of one to five
elements identified by a bullet (•), whether in a
box with a shaded or unshaded border
Expanded Problem Focused Examination – should
include performance and documentation of at least
six elements identified by a bullet (•), whether in a
box with a shaded or unshaded border
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1997 – Single Organ Systems
4 Types of Examination Cont’d
Detailed Examination – examinations other than
the eye and psychiatric examinations should
include performance and documentation of at least
twelve elements identified by a bullet (•), whether
in a box with a shaded or unshaded border
– Eye and psychiatric examinations should include
the performance and documentation of at least nine
elements identified by a bullet (•), whether in a box
with a shaded or unshaded border
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1997 – Single Organ Systems
4 Types of Examination Cont’d
Comprehensive Examination – should include
performance of all elements identified by a bullet
(•), whether in a shaded or unshaded box.
– Documentation of every element in each box with a
shaded border and at least one element in a box
with an unshaded border is expected.
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E/M Medical Decision Making
Medical decision making refers to the complexity
of establishing a diagnosis and/or selecting a
management option as measured by three elements
– the number of possible diagnoses and/or the
number of management options that must be
considered;
– the amount and/or complexity of medical records,
diagnostic tests, and/or other information that must
be obtained, reviewed and analyzed; and
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E/M Medical Decision Making Cont’d
– the risk of significant complications, morbidity
and/or mortality, as well as comorbidities,
associated with the patient's presenting problem(s),
the diagnostic procedure(s) and/or the possible
management options
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E/M – Medical Decision Making Cont’d
Type of decision making is based on meeting the
requirements for two of the three elements
4 Types of Decision Making
–
–
–
–
Straightforward
Low Complexity
Moderate Complexity
High Complexity
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Number of Diagnoses or Management
Options
This element is based on the following:
– The number and types of problems addressed
during the encounter
– The complexity of establishing a diagnosis
– The management decisions made by the physician
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Amount and/or Complexity of Data to be
Reviewed
The amount and/or complexity of data or other
information that must be obtained, reviewed and
analyzed in order to establish a diagnosis is
another indicator of complexity of diagnostic or
management problems
Always remember to document the rationale for
ordering diagnostic testing or other ancillary
service
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Table of Risk
The risk of significant complications, morbidity,
and/or mortality is based on the risks associated
with the presenting problem(s), the diagnostic
procedure(s) ordered, and the management option
selected
The highest level of risk in any category
determines the overall risk
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Table of Risk Cont’d
The assessment of risk of the presenting
problem(s) is based on the risk related to the
disease process anticipated between the present
encounter and the next one.
The assessment of risk of selecting diagnostic
procedures and management options is based on
the risk during and immediately following any
procedures or treatment
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Documenting Medical Decision Making
Reviewers depend on the documentation in the
assessment and plan portion of the progress note
– Assessment should include the problems pertinent
to the specific encounter
– First listed should indicate the chief complaint
• Use symptoms when a definitive diagnosis has not
been established
• Acceptable to include differential diagnosis when
definitive diagnosis has not been established
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Documenting Medical Decision Making
Cont’d
– Comorbidities/underlying diseases or other factors
that increase the complexity of medical decision
making by increasing the risk of complications,
morbidity, and/or mortality should be documented
– If a surgical or invasive diagnostic procedure is
ordered, planned or scheduled at the time of the
E/M encounter, the type of procedure, eg,
laparoscopy, should be documented.
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E/M – Coding by Time
In the case where counseling and/or coordination
of care dominates (more than 50%) of the
physician/patient and/or family encounter (face-toface time in the office or other outpatient setting
or floor/unit time in the hospital or nursing
facility), time is considered the key or controlling
factor to qualify for a particular level of E/M
services
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Coding by Time
Documentation Requirements
Documentation requirements
– Total face-to-face or floor/unit time (in minutes)
– Amount of time spent in counseling/coordination
of care (in minutes)
– Synopsis of the counseling/coordination of care
that took place
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Time-Based Codes
Code selection is strictly based on time (list is not
all-inclusive)
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–
–
–
–
–
Inpatient discharge day management
Nursing facility discharge day management
Prolonged services
Tobacco/Smoking Cessation Counseling
Critical care
Psychotherapy
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Discharge Day Management
Includes final examination of the patient, discussion of
the hospital stay, instructions for continuing care, and
preparation of discharge records (when performed on
the floor/unit)
– 30 minutes or less (e.g., 99238)
– More than 30 minutes (e.g., 99239)
Time spent discharging the patient must be
documented
– Medicare teaching physician guidelines, code for time
the faculty physician personally spends discharging the
patient.
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“Incident To” OIG Settlement 1/16/2013
After it self-disclosed conduct to the OIG, Bartlett
Regional Hospital (Bartlett), Arkansas, agreed to
pay $1,434,664.50 for allegedly violating the Civil
Monetary Penalties Law
– The OIG alleged that Bartlett submitted claims
using incorrect physician names and NPI numbers
and submitted claims for non-physician provider
services that were billed under a physician's name
and NPI number
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Medicare Billing Options for Selected
Nonphysician Practitioners
Medicare Option 1
– Must bill rendering provider using NPP’s name and
NPI
•
•
•
•
New patients
Established patients with new complaints
Established patients requiring change in treatment plan
Any surgical service that has not been ordered by the
physician during a previous visit
• All preventive services
• Test interpretations, e.g., EKG, x-rays
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Nonphysician Practitioner Services
Incident To Billing Cont’d
Medicare Option 2
– Incident to Billing
• Place of service office
• Billing physician must be physically present in the
office suite and immediately available
• Established patient
• Physician established treatment plan for problem
during a previous visit – NPP is providing a followup visit
– Cannot change plan
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Nonphysician Practitioner Services
Shared Visits
Medicare Option 3
– Patient seen by both the physician and NPP
– Shared visit concept only applies to certain E/M
codes
– Shared visit concept does not apply to (List is not
all-inclusive)
• Critical care codes
• Nursing facility services
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Shared Visits Cont’d
Place of service office
– If “incident to criteria is met – can use either the
physician or NPP’s name and NPI
– If “incident to” is not met – MUST be billed using
the NPP’s name and NPI
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Shared Visits Cont’d
Place of service emergency department, outpatient
hospital, inpatient hospital
– If both physician and NPP see the patient and
document their own services, can use either
physician’s or NPP’s name and NPI
– If only seen and documented by physician – Must
be billed by the physician
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Hospital Shared Visits Cont’d
– If only seen and/or documented by NPP – Must be
billed by the NPP
– If seen by NPP who documents his/her service and
seen by the physician who does not document
his/her own service (history, exam, MDM) – Must
be billed by NPP
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Billing Services Performed by
Nonphysician Practitioners
Medicare and all federal plans that follow Medicare
guidelines (list is not all-inclusive)
– Tri Care
– Mail Handlers Benefit Plan (MHBP)
– Federal Employee Blue Cross Blue Shield
– GEHA - Government Employees Health Association
– NALC - Nationwide National Association of Letter
Carriers
– SAMBA - Federal Employee Benefit Association
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Nonphysician Practitioner Services
Commercial Insurers
Aetna
– If Medicare’s “incident to” guidelines are met, may bill
using either the physician or NPP’s name and NPI
– If Medicare’s “Incident to” guidelines are not met,
MUST bill using the NPP’s name and NP
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Injections – Documentation Required
Must be ordered by Physician/nonphysician provider
– Name of medication documented
– Strength documented
– Dosage documented
Method of administration
Location of injection
Identity of individual administering injection
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Injections - Insufficient Documentation
Physician Billed HCPCS J1885 (ketorolac
tromethamine, per 15 mg) and J3420 (vitamin B12 cyanocobalamin, up to 1000 mcg)
– Orders received for medications, however, no
documentation received to support medications
were administered
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Vitamin B-12 Injection
The patient’s medical record must contain documentation that
fully supports the medical necessity for services included within
this LCD (See “Indications and Limitations of Coverage and/or
Medical Necessity”).
– This documentation includes, but is not limited to, relevant
medical history, physical examination, and results of
pertinent diagnostic tests or procedures.
– Except for patients who have had a complete surgical
resection of either the stomach or ileum OR currently
receiving chemotherapy with certain drugs, documentation
should include
• Vitamin B12 deficiency not corrected by oral dosing
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Vitamin B-12 Injection Cont’d
Deficiency documented by serum assay
– B12 levels below 100pg/mL suggest deficiency
– Test results between 100-400pg/mL may require
further testing
• Tests to consider include serum homocysteine,
serum methylmalonic acid (MMA), and serum
HoloTC-II (active vitamin B12) assays
(Dharmarajan, et al.)
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Vitamin B-12 Injection Cont’d
– When a patient shows neuropsychiatric
abnormalities and the serum B12 is low normal,
i.e., below 350 pg/ml, the physician may, in the
absence of methylmalonic acid or homocysteine
tests, presume a B12 deficiency and treat the
patient with B12
– Likewise if MMA and/or homocysteine level (s)
are available it is also appropriate to justify
treatment if these levels are abnormal
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Documentation Requirements for
Diagnostic Tests
If a diagnostic test is performed in the office, be
certain that the order is noted somewhere in the
medical record
Test requisitions for tests to be performed by another
entity must be personally signed by the provider
– Exception – requisition for clinical laboratory tests do
not have to be personally signed
Some tests require a written interpretation and report,
e.g., ECGs, x-rays
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Documentation Requirements for
Diagnostic Tests Cont’d
The claim must include the valid NPI of the
ordering/referring physician or extender
– Individual ordering the test in the medical record must
be shown as the ordering provider on the claim (Box 17
& 17b of CMS 1500) for the diagnostic test
Order for test(s) to be performed – must be specific –
requisition is NOT sufficient
Date of service documented
– Date of service matches date billed
Evidence physician reviewed results (e.g., x-ray reports,
laboratory tests, etc.)
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CERT - Insufficient Documentation –
Physician Billed CPT 93000
Missing a copy of the 12 lead electrocardiogram
interpretation report for billed date of service
– Received copy of ECG tracing
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Medically Unnecessary Service or Treatment –
Physician Billed CPT 93010 (ECG Interpretation)
No order was submitted for the inpatient
electrocardiogram, routine ECG with at least 12
leads.
The ECG tracing, with the interpretation and
report, were received without the order and there
was no response to follow-up requests
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Recommended Documentation for
Surgical Procedures (As Appropriate)
Reason for performing the procedure
Consent
Prep
Type and amount of anesthesia (if appropriate)
Description of the procedure including the
location, instruments used, technique, sutures, etc
Cont’d next slide
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Recommended Documentation for
Surgical Procedures (As Appropriate)
Continued from previous slide
Bandage
Completed with/without complication
How patient tolerated the procedure
Postop instructions given to the patient
Pre and postoperative diagnoses
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Billing and Coding for Osteopathic
Manipulative Treatment
Article published in the Journal of the American
Osteopathic Association (JAOA)
http://www.jaoa.org/content/109/8/409.full
– Somatic dysfunction is defined in the AOA-sponsored
textbook Foundations for Osteopathic Medicine as
follows:
• Impaired or altered function of related components of the
somatic (body framework) system: skeletal, arthrodial,
and myofascial structures, and related vascular,
lymphatic, and neural elements
• Somatic dysfunction is treatable using osteopathic
manipulative treatment
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Billing and Coding for Osteopathic
Manipulative Treatment Cont’d
The textbook further states that somatic
dysfunction is “diagnosed by history and palpatory
assessment of tenderness, asymmetry of motion
and relative position, restriction of motion, and
tissue texture change.”
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Billing and Coding for Osteopathic
Manipulative Treatment Cont’d
Except for tissue texture changes, evaluation for somatic
dysfunction is part of the standard musculoskeletal
physical examination.
As outlined by CMS, a complete single-organ system
musculoskeletal examination consists of assessing the
following elements:
–
–
–
–
–
–
gait
palpation of asymmetry and tenderness
range of motion
stability
muscle strength and tone
digits and nails
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OMT Codes
Coding is based on the number of regions treated:
–
–
–
–
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98925 for 1-2 body regions
98926 for 3-4 body regions
98927 for 5-6 body regions
98928 for 7-8 body regions
98929 for 9-10 body regions
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OMT Coding Cont’d
Body Regions:
–
–
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–
–
–
–
–
–
–
Head
Cervical
Thoracic
Lumbar
Sacral
Pelvic
Lower Extremities
Upper Extremities
Rib Cage
Abdomen and Viscera
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Billing an E/M on the Same Day as
OMT
For the purposes of billing visits on the same day
as OMT, CMS assigned “0” postoperative days
making these codes “minor surgical procedures”
Must follow CMS minor surgical procedure
billing rules
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Billing an E/M on the Same Day as
OMT Cont’d
Documentation Requirements
– Separate the documentation for the visit (SOAP
note) and OMT
– Clearly label OMT
Append modifier -25 to the visit code to indicate a
significant, separately identifiable service was
performed on the same day as OMT
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WPS Clarification for Using
Modifier -25
Modifier 25 is used to identify a significant,
separately identifiable service on the same day as
a procedure
– This means the E/M is above and beyond what
would be provided as part of the procedure
– The documentation must show the additional work
and someone else looking at the documentation
must be able to identify that work separate from the
procedure
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National Correct Coding Initiative
Also known as “bundling edits.”
Implemented by CMS and promotes correct coding
methodologies.
Controls the improper assignment of codes that results
in inappropriate reimbursement.
Additional information is available on the CMS
website
http://www.cms.hhs.gov/NationalCorrectCodInitEd/
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National Correct Coding Initiative
Edits
CCI Manual
– The decision to perform a minor surgical procedure is
included in the payment for the minor surgical
procedure and should not be reported separately as an
E/M service
– However, a significant and separately identifiable E/M
service unrelated to the decision to perform the minor
surgical procedure is separately reportable with
modifier -25
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CCI Manual Cont’d
The E/M service and minor surgical procedure do not
require different diagnoses
If a minor surgical procedure is performed on a new
patient, the same rules for reporting E/M services
apply
– The fact that the patient is “new” to the provider is not
sufficient alone to justify reporting an E/M service on
the same date of service as a minor surgical procedure
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CCI Example
If a physician determines that a new patient with head
trauma requires sutures, confirms the allergy and
immunization status, obtains informed consent, and
performs the repair, an E/M service is not separately
reportable
However, if the physician also performs a medically
reasonable and necessary full neurological
examination, an E/M service may be separately
reportable
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CMS - E/M with Minor Surgical
Procedure
Payment for minor surgical procedures includes payment
for certain E/M services that are necessary prior to a
procedure being performed
– It may be necessary to indicate that on the day a
procedure or service was performed, the patient's
condition required a significant, separately identifiable
E/M service above and beyond the usual preoperative
and postoperative care associated with the procedure
that was performed
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CMS Decision for Minor Procedure
Modifier -25 is not used to report an E/M service that
resulted in a decision to perform surgery
– The -57 modifier is not used with minor surgeries
because the global period for minor surgeries does not
include the day prior to the surgery
– Moreover, where the decision to perform the minor
procedure is typically done immediately before the
service, it is considered a routine preoperative service
and a visit is not billed in addition to the procedure
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Decision for Minor Procedure Cont’d
Carriers should not pay for an evaluation and
management service billed with the CPT modifier
-57 if it was provided on the day of or the day
before a procedure with a 0 or 10-day global
surgical period
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Department of Justice Settlement
April 3 - St. Luke’s University Health Network has agreed
to pay $1,029,791 to resolve allegations that from January
1, 2002, through June 30, 2012, it erroneously submitted
claims to the Medicare program for evaluation and
management services that were not allowable under
Medicare.
– Medicare does not normally allow additional payment
for visits performed by a provider on the same day as a
minor surgical procedure, unless the service is
significant, separately identifiable, and above and
beyond the usual preoperative and postoperative
care associated with the procedure
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Department of Justice Settlement
Cont’d
• In such cases, an attachment to the claim, known as
"Modifier -25," may be submitted to allow the
additional payment
– In this matter, the government determined that St.
Luke’s incorrectly attached Modifier -25 to Medicare
claims that led Medicare to pay for evaluation and
management services that were not significant and
separately identifiable from the underlying procedures
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Intravitreal Injections - OIG Findings for
Fletcher Allen Health Care
The Hospital and its physicians did not always comply
with Medicare requirements for separately billable E/M
services related to outpatient eye injection procedures.
– The Hospital correctly billed for 15 of the 100 E/M services
that we sampled. However, the Hospital incorrectly billed
for the remaining 85 services. The incorrect billing resulted
in overpayments totaling $8,063.
– Based on these sample results, the OIG estimated that the
Hospital and its physicians received overpayments totaling
$211,196 for CYs 2008 through 2010.
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OIG Findings - Fletcher Allen
Health Care Cont’d
The Hospital and its physicians were not eligible
for the additional E/M payments since the services
that the physician performed were not significant,
separately identifiable, and above and beyond the
usual preoperative work of the eye injection
procedure
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Fletcher Allen Health Care
Response
The billing errors occurred because the providers
believed in good faith that the care they provided
included a separately billable E/M service.
In all of the sampled claims, the provider not only
assessed and prepared the patient for the eye
injection and provided the injection, he or she also
examined the patient's other eye and assessed the
potential effects of the patient's other conditions,
such as diabetes and hypertension, on that eye
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Fletcher Allen Health Care
Response Cont’d
The providers feel that this approach promotes
efficient and high quality medical care, and likely
reduces the need for additional visits
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OIG Findings - Fletcher Allen
Health Care Cont’d
Overpayments occurred because the Hospital had
inadequate billing system controls over billing
E/M services related to outpatient eye injection
procedures, and the Hospital’s physicians, who
performed the eye injection procedures, did not
fully understand the Medicare requirements for
separately billable E/M services
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OIG Recommendations – Fletcher
Allen Health Care
OIG recommended that the Hospital
– refund to the Medicare contractor $211,196 in
estimated overpayments
– strengthen controls in the billing system to ensure
full compliance with Medicare requirements
– strengthen its education to physicians regarding
separately billable E/M services related to eye
injection procedures
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Thanks for attending!
See you in December