Should you be worried?

Audit risks for practices have never been higher. The Office of the Inspector General (OIG) for the Department of Health and Human Services issues an annual work plan, and the 2011 version lists a minimum of 18 projects that may have relevance to an orthopaedic practice. This article discusses some, but not all, of the major areas that are likely targets.

Surgeons need to alert staff that brushing aside letters and requests from Federal agencies and their agents or those from health plans is not a good strategy. If it’s bad news, you want to hear about it earlier rather than later.

High-dollar payments for Medicare Part B claims
Recently, the OIG conducted national evaluations of Medicare contractors. Their objective was to determine whether high-dollar Medicare payments for services were appropriate.

Specifically, the OIG put emphasis on the units billed and the quantities that were shown for different services. They looked to determine whether or not the actual quantities and units billed were supported in the claim records.

The OIG considered these high-dollar claims to be at risk for overpayment.

Incorrect billing for drugs and biologic “units or service” was the most significant factor influencing the identification of errors in the high-dollar reports. Providers must follow Medicare guidelines for billing drugs and biologics to receive payment based on the coverage criteria. Units billed should reflect the amount documented within the medical record.

OIG identified several claims with billing errors and/or overpayments. The following were the most common reasons for flagging a claim:

• Providers incorrectly claimed excessive units of service.
• The dosage or the number of units was billed incorrectly.
• Providers improperly coded claims.
• Provider records contained insufficient documentation.
• The per unit payment amount exceeded per unit allowed amount on the Medicare fee schedule.

Here is how these errors might occur in your practice.

Excessive units
In one example, a practice billed CPT code 28011 (Tenotomy, percutaneous, toe; multiple tendons) five times on one foot. Medicare denied the entire claim as too many units on the same date of service. Although this situation was identified and denied on the front end, it very well could have been found during data mining by audit contractors.

Incorrect dosage billed
Medicare monitors the number of units billed on all drugs. A recent review of 25 office notes for billing a joint injection had documentation that supported the drug administered, but information was missing. The documentation was missing either the total number of milligrams or the number of milligrams per cubic centimeter, which are required to accurately select the appropriate J code.

Improperly coded claims
Another practice reported an irrigation and débridement and wound repair on a postoperative dehiscence performed in the office during the global period of a hip replacement. The claim had the correct place of service, but was billed with modifier 78 (unplanned return to the operating room). Although Medicare paid this claim, the practice, if audited, should expect a request from the Centers for Medicare & Medicaid Services for a refund.

The OIG Work Plan includes a check matching place of service to the services performed during the global period.

Insufficient documentation
On the one hand, the adoption of electronic medical records and electronic health records is supported by various health information technology initiatives. On the other hand, the lack of oversight within a practice on how these systems are being implemented, heavy dependence by providers on the evaluation and management (E&M) code selection logic by the software, and physician behavior associated with importing and copying previous dates of service notes are raising red flags.

Medicare has seen a shift to higher levels of E&M service (codes 99214 and 99215). When was the last time anyone profiled and analyzed your E&M distribution? The new Code-X program makes this easy to do.

Overpayments
Although rare, overpayments by Medicare can happen. Medicare’s refund policy states that any overpayments must be refunded within 30 days of discovery. Overpayments are not “yours to keep”; refunds are a liability to the practice and timely paybacks are advised.

You can read more about refunds from the OIG on their official Web site, http://oig.hhs.gov/index.asp

Pay close attention to business practices within the office and adhere to your compliance plan. Now is the time to begin identifying any risks within the practice and to develop action plans to close the gaps and correct any business processes.

Next month, AAOS Now will review two other audit processes that could affect orthopaedic practices—Recovery Audit Contractors and Comprehensive Error Rate Testing.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. The article has been reviewed by the AAOS Coding, Coverage, and Reimbursement Committee.