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UASI Analysis of the OIG Work Plan February 2020

February 1, 2020

By: Natalie Sartori M.Ed., RHIA, CCS

This white paper presents an analysis of new and ongoing initiatives under the OIG Work Plan as of February 2020.[1] The paper focuses on initiatives related to HIM coding and documentation requirements and is not intended to review each and every active work plan item. Overlapping active work plan items have been grouped together to facilitate efficiency in developing your compliance plan. For each relevant initiative, the paper includes a summary of the OIG compliance concern, the month and year of the initiative and related coding and documentation requirements. More importantly, for each initiative, UASI has included specific suggested compliance activities to assist our clients’ with their ongoing compliance efforts.

This white paper includes an analysis of the following active OIG Work Plan topics:

  • Risk Scores
  • Facet Joint Injections
  • Provider Monthly ESRD Services
  • Facility ESRD Dialysis Services
  • Inpatient Hospital Billing
  • Critical Care E/M
  • Cardiac and Pulmonary Rehabilitation

Risk Scores

The Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Category (HCC) risk adjustment model is used to calculate risk scores, which will adjust capitated payments made for aged and disabled beneficiaries enrolled in Medicare Advantage (MA) and other plans. CMS pays a per-member per-month fee to the payer based on the prospective year’s risk scores. Risk scores identify all chronic conditions and/or severe diagnoses for patients in a given year. Risk scores are obtained from multiple encounter types including inpatient, observation, and office/clinic visits. In reviewing the recently added and active items in the OIG work plan, there are multiple entries regarding assessing risk adjusted data for Medicare Advantage organizations (MAOs).

OIG Workplan Summary

A. Impact of Health Risk Assessments on Risk-Adjusted Payments in Medicare Advantage (2/2020)

Under Medicare Part C, the CMS makes advanced monthly payments to MAOs for each beneficiary enrolled. CMS risk adjusts these payments based on beneficiaries’ demographic information and clinical diagnoses from the prior year to pay MAOs more for beneficiaries with higher expected costs. MAOs submit encounter data to CMS, which are records of services provided to beneficiaries, including all diagnoses. Currently, CMS includes diagnoses from health risk assessments, which are visits to evaluate a beneficiary’s health risks, when calculating risk scores and risk-adjusted payments. All newly enrolled Security Health Plan Medicare Advantage members are encouraged to complete an HRA within 90 days of enrollment. This is allowed regardless of whether these diagnoses are supported by another service rendered to the beneficiary during that year. The OIG will conduct a study to determine the extent to which diagnoses solely generated by health risk assessments were associated with higher risk scores and higher MA payments.

B. Medicare Advantage Risk-Adjustment Data – Targeted Review of Documentation Supporting Specific Diagnosis Codes (11/2019)

Payments to MAOs are risk-adjusted on the basis of the health status of each beneficiary. MAOs are required to submit risk-adjustment data to CMS in accordance with CMS instructions, and inaccurate diagnoses may cause CMS to pay MAOs improper amounts. In general, MAOs receive higher payments for sicker patients. CMS estimates that 9.5 percent of payments to MAOs are improper, mainly due to unsupported diagnoses submitted by MAOs. Prior OIG reviews have shown that some diagnoses are more at risk than others to be unsupported by medical record documentation. The OIG will perform a targeted review of these diagnoses and will review the medical record documentation to ensure that it supports the diagnoses that MAOs submitted to CMS for use in CMS’s risk score calculations and determine whether the diagnoses submitted complied with Federal requirements.

Below is a list of ten HCCs that contained over half of the diagnoses that are considered high risk for improper payments. These were identified in a December 2019 OIG report “Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns” [2] The OIG undertook this study because of concerns that MAOs may use chart reviews to increase risk-adjusted payments inappropriately. Unsupported risk-adjusted payments are a major driver of improper payments in the MA program, which provided coverage to 21 million beneficiaries in 2018 at a cost of $210 billion. MAOs report these diagnoses via CMS’s MA encounter data system and Risk Adjustment Processing System (RAPS) based on services and chart reviews. MAO’s review a beneficiary’s medical record to identify diagnoses that a provider did not submit or submitted in error. CMS does not require MAOs to link these chart reviews to a specific service associated with the diagnoses. The OIG believes this may provide MAOs opportunities to circumvent CMS’s face-to-face requirement and inflate risk-adjusted payments inappropriately.

HCCDescription
108Vascular Disease
018Diabetes With Chronic Complication
111Chronic Obstructive Pulmonary Disease
085Congestive Heart Failure
058Major depressive, Bipolar, and Panic Disorders
022Morbid Obesity
040Rheumatoid Arthritis and Inflammatory Connective Tissue Disease
055Drug/Alcohol Dependence
008Metastatic Cancer and Acute Leukemia
096Specified Heart Arrhythmias

C. Risk Adjustment Data – Sufficiency of Documentation Supporting Diagnoses (10/2017)

Payments to MAOs are risk-adjusted based on the health status of each beneficiary. MAOs are required to submit risk adjustment data to CMS, in accordance with CMS instructions, and inaccurate diagnoses may cause CMS to pay MAOs improper amounts. In general, MAOs receive higher payments for sicker patients. CMS estimates that 9.5 percent of payments to MAOs are improper, mainly due to unsupported diagnoses submitted by MAOs. Prior OIG reviews have shown that medical record documentation does not always support the diagnoses submitted to CMS by MAOs. As of October, 2017, the OIG will review medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS’s risk score calculations and determine whether the diagnoses submitted complied with Federal requirements.

UASI Suggested Compliance Activities

Review of these work plan items clearly indicates that HCC risk-adjusted payments continue to be scrutinized. Healthcare organizations should assess the extent of their risk-adjusted patient population(s) to determine their level of risk. Organizations with significant risk-adjusted patient populations should ensure their compliance program is monitoring the accuracy of HCC reporting using internal and/or external data quality audits. [3, 4, 5]

  1. Use data analytics to identify HCCs for review.
    • Leverage internal data (e.g. disease registries, coded claims data) and external data sources (e.g. disease prevalence data)
    • Use EHR data to identify populations of patients with a high likelihood of specific chronic diseases and reconcile clinical and claims data
    • Include a focus audit that analyzes high risk HCCs identified by OIG that are also high volume HCCs for your organization.
    • Address any previously identified aberrant coding/reporting patterns
    • Identify and address areas of concern before the end of year final submission
    • For optimal risk assessment, include all applicable encounter types for each selected patient
  2. Conduct regular monitoring for common risk-adjusted documentation/coding errors, including for example:
    • Ensure clinical documentation in the patient’s medical record supports the presence of the HCC condition and indicates the qualified provider’s assessment and/or plan for management of the condition.
    • Ensure that all reported diagnoses are monitored, evaluated, assessed or treated during the encounter and documented as a result of a face to face visit.
    • Ensure conditions that are no longer treated are not reported, this includes for example problem list diagnoses that have resolved.
    • Report “history of” and “status” codes when the historical condition or family history has an impact on current care or influences current treatment.
  3. Review for both the addition and deletion of diagnosis codes
    • Chart review should be unbiased, seeking to ensure compliance with HCC reporting requirements. An important finding in the December 2019 OIG Report [2] was that charts audits were used exclusively to add codes to increase payments and never to delete codes and decrease payments.
    • A chart review program, designed solely to identify missed diagnoses, that does not also address correcting unsupported diagnoses, may be deemed fraudulent
  4. Develop corrective action plans, including physician and coder education, based on audit findings. Examples of provider documentation best practices include:
    • Document all cause and effect relationships
    • Clearly link complications or manifestations of a disease process
    • Include all current diagnoses as part of the current medical decision-making process and document them in the note for every visit
    • Only document diagnoses as “history of” or “past medical history (PMH)” when they no longer exist or are not a current condition, for example history of an acute myocardial infarction or amputation status
    • Consider developing documentation tip sheets for HCCs to educate providers on what documentation is needed to substantiate reported diagnosis. The list of high risk HCCs can be the starting point for this initiative.

Facet Joint Injections

Facet joints are joints in the spine that aid stability and allow the spine to bend and twist. Facet joint injections are a type of interventional pain management technique used to diagnose or treat back pain. Medicare Part B payments for facet joint injections have increased from $141 million in 2003 to $307 million in 2006. Over the same period, the number of Medicare claims for facet joint injections increased by 76 percent. CMS conducted a medical record review of a stratified random sample of 646 facet joint injection services performed in 2006. [6] Findings of this audit included:

  • Sixty-three percent of facet joint injection services allowed by Medicare in 2006 did not meet Medicare program requirements, resulting in approximately $96 million in improper payments.
  • Thirty-eight percent of facet joint injection services had a documentation error and 31 percent had a coding error. For services that had a coding error, just over 60 percent were overpaid because physicians incorrectly billed additional add-on codes to represent bilateral facet joint injections instead of using modifier 50.
  • Eight percent of services had a medical necessity error.

OIG Work Plan Summary

A. Review of Medicare Facet Joint Procedures (08/2019)

Facet joint injections are an interventional technique used to diagnose or treat back pain. Several previous reviews found significant billing errors in this area, including a prior OIG review. The OIG will review whether payments made by Medicare for facet joint procedures billed by physicians complied with Federal requirements.

Coding Guidelines for Facet Joint Injections

  • Because of the diagnostic nature of facet blocks, precise localization is necessary. Therefore, it is expected that use of the facet codes (CPT 64490-64495) would require fluoroscopic or CT image guidance. Consequently, imaging guidance (fluoroscopy CT) and any injection of contrast are inclusive components of CPT codes 64490-64495 and are not reported separately.
  • Blocks performed without the use of fluoroscopy are considered not medically necessary.
  • An injection may be placed in the facet joint itself or around the medial branch nerve innervating the joint. In general, it is believed that two to three medial branch nerves innervate each lumbar facet joint and two nerves innervate each cervical or thoracic facet joint. These nerves are the branches of the posterior division of the spinal nerves, located immediately above and below the joint. CPT codes 64490 and 64493 are intended to be used to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve.
  • Likewise, CPT codes 64491, 64492 and 64494, 64495 are intended to report second and third additional level paravertebral facet joints and not each additional nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them as defined by the AMA CPT Committee.
  • CPT codes 64490-64495 are unilateral procedures. When bilateral injections are performed (e.g., injections performed at both the left and right paravertebral facet joints), then the bilateral modifier 50 should be appended to the first level codes (64490 and 64493).
  • Report add-on CPT codes 64491, 64492, 64494, 64495 twice, when performed bilaterally. Do not report modifier 50 in conjunction with codes 64491, 64492, 64494, 64495.

The cervical/thoracic facet injection codes (64490, 64491 and 64492) and lumbar/sacral facet joint injection codes (64493, 64494 and 64495) are reported once when the injection procedure is performed irrespective of whether a single or multiple puncture is required to anesthetize the target joint at a given level and side. To clarify, only one facet injection code should be reported at a specific level and side injected (e.g., right L4-5 facet joint), regardless of the number of needle(s) inserted or number of drug(s) injected at that specific level.

UASI Suggested Compliance Activities

  1. Identify the risk
    • Run a report for CPT codes 64490 – 94495 to determine frequency of reporting in claims data
    • Determine if these CPT codes are hard coded (from the chargemaster) or soft-coded (manually)
  2. Assess the risk
    • Analyze coded claims data for facet joint injections to identify aberrant coded data based on algorithms applying the coding guidelines.
    • Conduct a random sample coding audit to assess coding accuracy based on:
      • The CPT Guidelines for codes 64490-64496. (Note: CPT guidelines for these codes were revised for CPT 2020.)
      • Review your applicable LCD policy and internal guidelines to include any additional coding criteria specified outside of CPT guidelines
      • Identify diagnosis and documentation requirements necessary to meet medical necessity criteria based on your LCD.
  3. Record findings and categorize the risks
    • Identify and tally each error by type such as CPT coding, chargemaster, modifiers or medical necessity errors.
  4. Develop an action plan that may include one or more of the following:
    • Creation or revision of facility coding guidelines
    • Revise and correct Chargemaster
    • Coder education/tip sheets
    • Physician education on documentation requirements
    • Timeframe for follow up audit to assess effectiveness of corrective action

Provider Monthly End Stage Renal Disease Services

The Comprehensive Error Rate Testing (CERT) contractor conducted a special study of the Healthcare Common Procedure Coding System (HCPCS) codes for the following end-stage renal disease (ESRD) related services:

  • 90960 – ESRD related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month
  • 90961 – ESRD related services monthly, for patients 20 years of age and older; with 2-3 face-to-face visits by a physician or other qualified health care professional per month.

The study [7] showed approximately one third of the payments for ESRD related services were improper payments. The majority of the improper payments were due to insufficient documentation. The rest of the improper payments were due to incorrect coding or no documentation submitted. There were no claims with medical necessity errors in the special study. Insufficient documentation in this study meant that something was missing from the medical records. For example, there was:

  • No physician’s signature on an order; or
  • No documentation of the provider’s face-to-face encounter(s).

OIG Work Plan Summary

A. Review of Monthly ESRD-Related Visits Billed by Physicians or Other Qualified Healthcare Professionals (04/2019)

Most physicians and other practitioners (e.g., clinical nurse specialists, nurse practitioners, or physician’s assistants) who manage the care of patients who receive outpatient dialysis services at ESRD facilities are paid a monthly capitation payment (MCP) for ESRD-related physician services. The MCP amount is based on the number of visits provided within each month and the age of the ESRD beneficiary. The physician or other practitioner can bill only one of three CPT codes for ESRD-related visits of one per month, two to three per month, or four or more per month. The CERT program’s special study of the HCPCS codes for ESRD-related services [7] found that for some codes, approximately one-third of the payments for ESRD-related services were improper payments due to insufficient documentation, incorrect coding, or no documentation submitted. The OIG will review whether physicians or other qualified healthcare professionals billed monthly ESRD-related visits in accordance with Federal requirements.

UASI Suggested Compliance Activities

  1. Identify the risk
    • Run a report for CPT codes 90960 – 90961 to determine frequency of reporting in claims data
  2. Assess the risk
    • At a minimum conduct a random sample coding audit to determine if there is documentation of a face-to-face encounter by the provider to match the code description.
    • An initial audit can also include validation of ICD-10-CM diagnosis codes and the associated HCC reporting.
  3. Record findings and categorize the risks
    • Identify and tally documentation issues and/or coding issues
  4. Create an action plan
    • Determine how best to communicate findings to providers and what education is needed.
    • Provide audit feedback on coding accuracy along with the necessary education for coding errors.
  5. Conduct a follow-up audit to assess documentation and/or coding issue resolution.

Facility End-Stage Renal Disease Dialysis Services (06/2018)

The prospective payment system for End-Stage Renal Disease (ESRD) provides a single payment to ESRD facilities that will cover all of the resources used in furnishing outpatient dialysis treatment. This includes supplies and equipment used to administer dialysis (in the ESRD facility or at a patient’s home), drugs, biologicals, laboratory tests, training, and support services. The CMS website includes detailed Information on the lab tests, drugs and supplies subject to the ESRD consolidated billing requirement. [8]

OIG Work Plan Summary

Medicare Part B covers outpatient dialysis services for beneficiaries diagnosed with ESRD. Prior OIG work identified inappropriate Medicare payments for ESRD services. Specifically, OIG identified unallowable Medicare payments for treatments not furnished or documented, services for which there was insufficient documentation to support medical necessity, and services that were either not ordered by a physician or were ordered by a physician that was not treating the patient. Additionally, prior OIG reviews identified claims that did not comply with Medicare consolidated billing requirements.[8] The OIG will review claims for Medicare Part B dialysis services provided to beneficiaries with ESRD to determine whether such services complied with Medicare requirements.

UASI Suggested Compliance Activities

  1. Select audit sample to represent Medicare Part B ESRD services billed.
  2. Review medical record for the following elements: [9]
    • Signed/authenticated and dated order by an authorized CMS prescribing provider which notes frequency of dialysis treatment and method of dialysis
    • History and physical exam information supporting the diagnosis and treatment, along with relevant trends or status changes
    • Treatment/dialysis flow sheet documentation for each DOS billed which must include patient pre/post treatment weight, method of access, treatment start/end time, treatment record and patient assessment
    • Separate order and rationale for any extra dialysis treatments
    • Record of all medications administered
    • All progress notes including physician, nurse and other multi-disciplines including regular physician evaluations documenting efficacy of treatment
    • Documentation does not include vague descriptions (e.g. “patient remains stable.”)
    • Any additional requirements in organizational bylaws and policies.
  3. Review billed claims for charges related to lab tests drugs and supplies subject to consolidated billing.
  4. Record findings and categorize the risks
    • Identify and tally documentation issues and/or billing issues.
  5. Create an action plan
    • Utilize existing committee or create an appropriate interdepartmental team to address findings
    • Identify root causes of documentation and/or billing errors to clearly describe problem
    • Identify solutions to correct risk occurrences
  6. Conduct follow-up
    • Ensure effectiveness by observing the implemented solutions in operation

Inpatient Hospital Billing

This Work Plan item will likely result in a resurgence of DRG denials due to coding errors that resulted in overpayment. In light of this OIG initiative, Hospitals should review, and update if necessary, coding audit plans to ensure they are adequate to identify potential cases of up-coding. The Central Learning 2nd National ICD-10 Coding Contest findings revealed the inpatient coding accuracy rate is still well below the de facto standard of 95% accuracy.

OIG Work Plan Summary

A. Assessing Inpatient Hospital Billing for Medicare Beneficiaries (12/2018)

In 2016, hospitals billed Medicare $114 billion for inpatient hospital stays, accounting for 17 percent of all Medicare payments. The Centers for Medicare & Medicaid Services and the Office of Inspector General have identified problems with up-coding in hospital billing: the practice of mis- or over-coding to increase payment. The OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing. The OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. The OIG will subsequently use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.

UASI Suggested Compliance Activities

  1. Ensure the inpatient coding compliance program includes all essential elements. [10]
  2. Identify targeted coding areas for your organization that are prone to coding errors. Some common risk areas include:
    • Accounts with only one CC or MCC
    • High volume DRG pairs or triplet
    • Previously reported or identified coding issues
    • Percutaneous versus open approach for procedures
    • Spinal fusion procedures
    • Use compliance reports such as PEPPER to identify possible payment errors
  3. Determine if the risk areas identified can be integrated into existing compliance audits or if additional audits will be required and what resources are necessary.
    • Bi-annual or annual coding audits are no longer adequate given the complexity of ICD-10 coding and reimbursement.
    • Internal audits should be conducted based on staff availability with appropriate coding expertise and proficient in communicating feedback through written reports and educational sessions.
    • Examine how external audits should supplement and support your internal staff’s proficiency and availability to conduct audits.
  4. At a minimum inpatient audits should measure and validate
    • Accurate identification of principal and secondary diagnoses and procedures in accordance with official and facility coding guidelines
    • Accurate MS-DRG or APR-DRG assignment
    • Accurate POA indicator assigned for all non-exempt codes
    • Accurate Discharge Disposition assignment
  5. Analyze audit results to assess the root cause of any results that fall below the expected standard.
  6. Develop follow-up and education plans that are efficient and effective.

Critical Care E/M

Critical care is defined as a physician’s (or physicians’) direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system functions to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition. [11]

OIG Work Plan Summary

Physicians Billing for Critical Care Evaluation and Management Services (08/2018)

Critical care is defined as the direct delivery of medical care by a physician(s) for a critically ill or critically injured patient. Critical care is usually given in a critical care area such as a coronary, respiratory, or intensive care unit, or the emergency department. Payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. Critical care is exclusively a time-based code. Medicare pays physicians based on the number of minutes they spend with critical care patients. The physician must spend this time evaluating, providing care and managing the patient’s care and must be immediately available to the patient. The OIG review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.

UASI Suggested Compliance Activities

  1. Select audit sample. Depending on your volume of critical care reporting it may be appropriate to conduct audits based on physician group or location (e.g. ED, CCU, ICU) so that any action plan developed is specific to issues identified during the chart audit. For example, ED physicians may not adequately document time spent or hospitalists may not adequately document the ICU patients’ condition and treatment to meet complex medical decision making.
  2. Review medical record to verify the following elements:
    • A medical condition that impacts one or more vital organ system and conditions that can be imminently life threatening. [12]
    • Medical decision making should be highly complex.
    • The total time providing critical care is documented by the attending physician.
    • For provider audits include a review for procedures considered “bundled” into critical care billing are not being separately billed. [12]
  3. Record findings and categorize the risks
    • Identify and tally documentation issues and/or billing issues.
  4. Create an action plan
    • Utilize existing committee or create an appropriate interdepartmental team to address findings
    • Identify root causes of documentation and/or billing errors to clearly describe problem
    • Identify solutions to correct risk occurrences
  5. Conduct follow-up
    • Ensure effectiveness by conducting follow up audits.

Cardiac and Pulmonary Rehabilitation

OIG Work Plan Summary

A. Medicare Part B Outpatient Cardiac and Pulmonary Rehabilitation Services (05/2018)

Medicare Part B covers outpatient cardiac and pulmonary rehabilitation services. For these services to be covered, however, they must be medically necessary and comply with certain documentation requirements. Previous OIG work identified outpatient cardiac and pulmonary rehabilitation service claims that did not comply with Federal requirements. The OIG will assess whether Medicare payments for outpatient cardiac and pulmonary rehabilitation services were allowable in accordance with Medicare requirements. [13] The OIG will also determine whether potential risks in outpatient cardiac and pulmonary rehabilitation programs continue to exist.

UASI Suggested Compliance Activities

  1. Select audit sample to represent Medicare part B outpatient cardiac and pulmonary rehabilitation services
  2. Audit Cardiac Rehabilitation sample records to validate the following
    • Verify each account meets Medicare criteria for coverage. Coverage criteria require that patients must have one or more of the following conditions to be eligible for cardiac rehabilitation: [13]
      • Diagnosis of acute myocardial infarction within preceding 12 months; or
      • Have had coronary bypass surgery; or
      • Current stable angina pectoris; or
      • Have had heart valve repair/replacement; or
      • Have had percutaneous transluminal coronary angioplasty or coronary stenting; or
      • Have had a heart or heart-lung transplant; or
      • Have stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and NY Heart Association class II to IV symptoms despite being on optimal heart failure therapy for at least six (6) weeks
    • Validate the following is documented in the patient’s health record on each account:
      • Physician prescribed aerobic exercises combined with other types of exercises (such as strengthening or stretching
      • Cardiac risk factor modification (including education, counseling and behavioral intervention) tailored to the individual’s needs is documented at least once
      • Psychosocial assessment, that includes assessment of family and home situation, and evaluation of response to treatment
      • Outcomes assessment, based on patient centered outcomes measures, at the beginning and end of the program
      • An individualized treatment plan (ITP) detailing how components are utilized for each patient
      • The ITP must be signed prior to, or no later than, the patient’s first cardiac rehab session and include patient diagnosis, detailed description of CR services furnished and goals set for the plan
      • Any applicable LCD requirements
  3. Audit Pulmonary Rehabilitation records to validate the following: [14]
    • Verify each account has a diagnosis of moderate to severe Chronic Obstructive Pulmonary Disease to meet Medicare coverage requirement.
    • Validate the presence and quality of documentation for the following:
      • ITP signed prior to, or no later than, the patient’s first session
      • Physician order for exercise program
      • Physician prescribed education or training closely and clearly related to individual’s care and treatment which is tailored to their needs
      • Psychosocial assessment
      • Outcomes assessment
      • Any applicable LCD requirements
  4. Record findings and categorize the risks
    • Identify and tally documentation issues and/or billing issues.
  5. Create an action plan
    • Utilize existing committee or create an appropriate interdepartmental team to address findings
    • Identify root causes of documentation and/or billing errors to clearly describe problem
    • Identify solutions to correct risk occurrences
  6. Conduct follow-up
    • Ensure effectiveness by observing the implemented solutions in operation

End Notes:

  1. OIG Work Plan: https://oig.hhs.gov/reports-and-publications/workplan/index.asp
  2. Dept. of Health and Human Services, Office of Inspector General, Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns. OEI-03-17-00470, December 2019. https://oig.hhs.gov/oei/reports/oei-03-17-00470.pdf
  3. Watson, M, Casto, A, Davis, J, Stanfill, M. “Documentation and Coding Practices for Risk Adjustment and Hierarchical Condition Categories.” Journal of AHIMA 89, no.6 (June 2018): extended online version
  4. UASI. 2019 Passport to HCCs http://marketing.uasisolutions.com/passport-to-hccs-fy19
  5. HCPro. 2018 Outpatient CDI Pocket Guide: Focusing on HCCs. http://hcmarketplace.com/
  6. Dept. of Health and Human Services, Office of Inspector General, Medicare Payments For Facet Joint Injection Services. OEI-05-07-00200, September 2008. https://oig.hhs.gov/oei/reports/oei-05-07-00200.pdf
  7. CMS, Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors, volume 5, issue 3, April 2015 pp. 1-3. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909208.pdf
  8. ESRD PPS Consolidated Billing, Consolidated Billing Requirement, Payment for Renal Dialysis Services Billed by Other providers. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html
  9. Medicare Claims Processing Manual Chapter 8 – Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims (Rev. 4202, 01-18-19)
  10. DeVault, K., Stanfill, M. “Components of an Effective Inpatient Coding Compliance Program” Journal of AHIMA 90, no.7 (July-Aug 2019): 50-52.
  11. MLN Matters, Critical Care Visits and Neonatal Intensive Care (Codes 99291 – 99292). MM5993 July 9, 2008
  12. Dodd, Kenneth MD and Fan, Ted MD. “ED Charting and Critical Care Time” July 2017. https://www.aliem.com/charting-coding-critical-care-time
  13. United HealthCare MA Coverage Summary: Rehabilitation: Cardiac Rehabilitation Services (Outpatient) https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-coverage-sum/rehabilitation-cardiac-rehabilitation-services-outpatient.pdf
  14. CMS Medicare Benefit Policy, Pub 100-02, Transmittal 124, Change Request 6823: Pulmonary Rehabilitation Services.