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Coding Consult: Fraud busters have their eye on you (still)


Federal health care police have issued their 2002 work plan. Coding and billing misdeeds once again top the hit list.


Coding Consult

Fraud busters have their eye on you (still)

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Choose article section...Fraud busters have their eye on you (still) Coding and billing are still on the hit list Policing the delivery of preventive services

Federal health care police have issued their 2002 work plan. Coding and billing misdeeds once again top the hit list.

Lawrence W. Vernaglia, JD, MPH

The transition from Clinton to Bush promised a new era in health care enforcement. Here, after all, was a new president who vowed to streamline government while untangling the snarl of Medicare red tape and rules.

Well, what a difference a year makes. Not only have the events of Sept. 11 and thereafter redirected administration energies to more pressing matters, but the tape-cutting impulse has been curbed by the fear of appearing soft on wrongdoers or callous toward elderly Americans.

How else to explain the HHS Office of Inspector General's Work Plan for Fiscal Year 2002, released last October? Under OIG boss Janet Rehnquist, the work plan is startling in its resemblance to Clinton-era policies: About half of last year's projects are still on the agenda. Here's an overview of what you can expect in the coming months.

Coding and billing are still on the hit list

As in the past, Uncle Sam will be taking a long and undoubtedly hard look at how you code and bill and for what.

Physician evaluation and management codes. Despite years of haggling between physicians and HHS, E&M codes remain inconsistent, often irrelevant to typical physician-patient encounters, and steeped in language seldom used in medical records. Add the additional burden that two sets of documentation guidelines are now in use—the so-called 1995 and 1997 revisions,* either of which you may use—and it's no wonder E&M coding remains physicians' No. 1 bugbear.

Nevertheless, the OIG presses on. According to the work plan, the OIG "will determine whether physicians correctly coded [in-office] evaluation and management services . . . and effectively used documentation guidelines."

In a clear signal to carriers to step up their enforcement efforts, the OIG "will also assess whether carriers identified any instances of incorrect coding and what corrective actions they took."

Services and supplies incident to physicians' services. This is another area of billing where confusion reigns yet enforcement interests continue unabated. Under the rules, you may bill for services that are a subordinate part of what you do and are provided by other health care practitioners—physician assistants, nurse practitioners, physical therapists, and others.

Generally, such practitioners must be in your employ and work under your direct supervision. But here's where things start to get complicated. What, for instance, constitutes direct supervision? In the office setting, you must be available in your office suite, but does "suite" include the office above the office where the incident-to services are being provided? Does it include the office down the hall?

The employee requirement is also a muddle, as typified by the rules relating to PT services. While a practice can bill for incident-to services of employed physical therapists, the Centers for Medicare & Medicaid Services (formerly HCFA) has left it to local carriers whether to permit doctors to bill their PTs' services as private therapy practice claims (which carry fewer regulatory hassles). Amid this chaos, the OIG says it "will evaluate the conditions under which physicians bill 'incident to' services and supplies" because "questions persist about the quality and appropriateness of these billings."

Consultations. Under Medicare rules, doctors may bill for a consultation if it's made at the attending physician's request, if it includes an exam and review by the consulting physician, and if the resulting report is made part of the permanent medical record.

Using these criteria, the OIG intends to weed out inappropriate consultation charges. Investigations will also be aimed at gauging "the primary reasons for any inappropriate billings" and their "financial impact on the Medicare program."

Advance beneficiary notices. To be reimbursed privately for a service you know or believe Medicare doesn't consider medically necessary, you must notify patients in advance of providing the service that it may not be covered. This year, as in the past, the OIG says it has reason to believe that adherence to the advance-notice rule varies widely, "especially with respect to noncovered laboratory services." Hence, the office says, it will investigate to determine the "financial impact on beneficiaries and providers."

Policing the delivery of preventive services

Doctors who provide patients with too few—or too many—preventive or related services will also come under the OIG searchlight.

With passage of the Balanced Budget Act of 1997, Congress created four classes of covered preventive services: yearly mammograms for women 40 and over, screening Pap smears and pelvic exams every three years, colorectal screening, and bone mass measurements.

To evaluate "beneficiary access," the OIG will study whether physicians are doing enough to make these expanded preventive services available. On the flip side, the OIG plans to evaluate the "appropriateness and quality" of the bone mass measurements that have been performed.

Despite this varied enforcement menu, one defining feature is clear: In 2002, the OIG will continue investigating areas that are among the most baffling to doctors. Whether OIG actions will lead to recommendations to CMS to clarify the rules or whether they will simply lead to more physician prosecutions remains to be seen. In the meantime, you need to be vigilant and, when in doubt, consult your local Medicare carrier, a qualified health law expert, or CMS itself.

The author is a health care attorney with the firm Hinckley, Allen & Snyder LLP in Boston.

*For more on E&M documentation guidelines, see "Coding Consult: E&M: Out with the new, in with the old," Feb. 8, 2002.



Lawrence Vernaglia. Coding Consult: Fraud busters have their eye on you (still). Medical Economics 2002;5:20.

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