April 7 , 2008

Radiologists Should Heed the OIG’s Agenda
By Sheri Poe Bernard, CPC, CPC-H, CPC-P
Radiology Today
Vol. 9 No.7 P. 32

What are the hot coding audit topics for radiology in 2008? A good benchmark for compliance issues is Health and Human Services’ annual Office of Inspector General (OIG) Work Plan. This year it targets several areas specific to imaging services and several more general areas affecting radiology practices. The following are extractions from the 2008 OIG Work Plan, followed by insights to prevent audit problems in your practice based on targeted compliance areas.

Payments for Diagnostic X-Rays in Hospital Emergency Departments:
“We will review a sample of Medicare Part B paid claims and medical records for diagnostic x-rays performed in hospital emergency departments [EDs] to determine the appropriateness of payments. Radiology services furnished by a physician are reimbursed by the Medicare Physician Fee Schedule, provided the conditions for payment for radiology services at 42 CFR § 415.102 (a) and 42 CFR § 120 are met. ... We will determine the appropriateness of payments for diagnostic x-rays and interpretations.”

Insight: In its 2007 Work Plan, the OIG stated it would look at unnecessary repeat interpretations of ED x-rays, identified through the use of modifier 77. Based on last year’s work, the OIG is broadening its review of ED diagnostic x-ray reimbursement this year to “appropriateness of payment.” Practices should be alerted to perform a thorough self-audit of coding and billing practices to ensure that documentation is complete and medical necessity has been noted and coded appropriately, as these are the most common errors found in simple x-ray billings. Check local and national coverage decisions and query patients regarding symptoms if insufficient information is provided by the referring physician, since signs and symptoms are often acceptable diagnoses if findings are negative. Document specifically if a test is a screening test, as the diagnostic code assignments for screening exams are very specific.

Business Relationships and the Use of Magnetic Resonance Imaging Under the Medicare Physician Fee Schedule:
“We will review the arrangements under which magnetic resonance imaging (MRI) is provided under the Medicare Physician Fee Schedule. Section 1848 (a) (1) of the Social Security Act establishes the physician fee schedule as the basis for Medicare reimbursement for all physician services. We will describe relationships among physicians, billing providers, and others who work together to provide imaging services and determine whether these relationships affect levels of utilization. We will pay particular attention to financial relationships among the parties.”

Insight: Utilization of MRI, PET, and CT scans grew by 20% per year from 1999 to 2005, with the total allowed charges topping $7 billion in 2005. In its 2007 Work Plan, the OIG promised to examine the appropriateness of services provided in physician offices and the “nature of the growth” of these services. The incidence of Stark violations associated with imaging likely prompted this renewed effort in 2008. Radiology practices would be wise to review the Stark II and new Stark III guidelines regarding self-referrals and financial beneficiaries of service.

Geographic Areas With High Utilization of Ultrasound Services: “We will review services and billing patterns in geographic areas with high utilization of ultrasound services paid under the Medicare Physician Fee Schedule. Our review will examine disproportionately high Medicare-allowed charges and services per beneficiary and disproportionately high percentages of beneficiaries receiving ultrasound services relative to the rest of the country. Section 1848(a)(1) of the Social Security Act establishes the physician fee schedule as the basis for Medicare reimbursement for all physician services, and section 1862(a)(1)(A) provides that Medicare will pay for services only if they are medically necessary. In areas of high utilization of ultrasound services, we will examine service profiles, provider profiles, and beneficiary profiles.”

Insight: The OIG is increasingly targeting aberrant patterns in services and billing in its quest to reduce government spending and uncover fraudulent practices. The best defense a practice can have is to understand the patterns within its locality. Ultrasound is increasing due to its application in surgical guidance, but practices may want to keep their utilization within the parameters of the norm whenever possible.

Geographic Areas With a High Density of Independent Diagnostic Testing Facilities: “We will review services and billing patterns in geographic areas with high concentrations of independent diagnostic testing facilities (IDTF). An IDTF is a facility that performs diagnostic procedures and is independent of a physician’s office or hospital. It may have a fixed location or be a mobile entity, and the practitioner performing the procedures may be a nonphysician. IDTFs must meet performance requirements at 42 CFR § 410.33 to obtain and maintain Medicare billing privileges. A 2006 OIG review found numerous problems with IDTFs, including noncompliance with Medicare standards and potential improper payments of $71.5 million. In areas with a high density of IDTFs, we will examine service profiles, provider profiles, beneficiary profiles, and billing patterns.”

Insight: IDTFs that are sharing facilities with another Medicare supplier or provider, regardless of whether the sharing is accomplished through a shared expense or block lease, are going to come under close scrutiny. Providers may allow their contracts with IDTFs to expire and seek other sites for their testing.

The Best Defense
The best way to protect your practice is to develop among your staff a good understanding of the OIG’s targets for 2008 and eliminate as many risks to your practice as possible. A complete copy of the work plan can be downloaded at http://oig.hhs.gov/publications/docs/workplan/2008/Work_Plan_FY_2008.pdf.

— Sheri Poe Bernard, CPC, CPC-H, CPC-P, is the vice president of member relations at the American Academy of Professional Coders, which provides certified credentials to medical coders in physician offices, hospitals, and outpatient centers.