October 25, 2010

For the first time in several years, the Office of the Inspector General (OIG) has issued its annual prospective Work Plan without including any reference to interventional pain procedures.

Anesthesiologists and Pain Physicians

This does not mean that the federal government’s interest in eliminating improper payments for transforaminal epidural injections has abated, however. In August 2010, the OIG published a special report indicating that 34 percent of transforaminal epidurals allowed by Medicare in 2007 did not meet Medicare requirements, resulting in approximately $45 million in improper payments for professional services alone. The payments were considered improper because the associated claims lacked proper documentation, did not establish medical necessity for the procedure, or contained coding errors – and all but one were overpayments. The report recommended that the Medicare Part B (physician payment) contractors develop and enforce more local coverage determinations (LCDs) through automated “edits,” or claims processing software algorithms that reject claims lacking evidence, for example, of radiographic guidance where required by LCD. Further, the report called upon the contractors to perform more “medical reviews” to verify medical necessity.

Pain injections may have disappeared from the OIG Work Plan, but both pain specialists and anesthesiologists who bill for visits or evaluation and management (E&M) services should note the 2011 Work Plan statements regarding E&M services. The OIG plans to continue reviewing E&M claims:

1. To determine whether coding patterns vary by provider characteristics (this is obviously just a hypothesis, but it is one that may lay the groundwork for a future crackdown on miscoding);
2. To identify electronic health records (EHR) documentation practices that generate identical documentation across multiple cases, leading, for example, to coding all E&M services as Level 3, regardless of the content of the service, and 
3. To assess whether industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992. As with coding patterns, the OIG intends to examine a hypothesis here.

Readers should note the second item in the E&M review list and take care to document their chronic pain or peri-operative visits adequately to show that they assign Level 3 or higher only when the criteria for that Level are met, and not automatically. Also worthy of attention is a new target for review: compliance with assignment rules. The OIG is particularly interested in whether patients are billed for amounts exceeding the Medicare allowable, and whether they are informed as to their rights regarding potential billing violations.

Pain specialists who offer physical therapy services in their private offices or clinics should also be aware that outpatient PT provided by independent therapists who have high utilization rates are on the OIG’s watch list.

Hospitals

The 2011 Work Plan promises that the OIG will intensify its focus on hospital readmissions and other adverse events. Anesthesiologists have been hearing for some time that taking an ownership role in hospital quality improvement and reporting programs will help demonstrate their value to their institutions. This is even more important given the continuing OIG scrutiny of hospital billing for services to inpatients for hospital-acquired conditions (HACs, sometimes referred to as “never events”) as well as same-day readmissions.

The Work Plan for 2010 had announced plans to test the effectiveness of an edit implemented by CMS in 2004 to reject subsequent claims for beneficiaries whom the hospital readmitted on the same day. According to the Medicare Claims Processing Manual, if a same-day readmission occurs for symptoms related to or for evaluation or management of the prior stay's medical condition, the hospital is entitled to only one DRG group payment and should combine the original and subsequent stays in a single claim. This testing will continue through 2011.

The OIG will also carry forward the review of detection of and payments for adverse events that it began this year. In particular, it will examine the early implementation of Medicare’s policy on HACs. Beginning on October 1, 2008, the HAC policy barred additional payment for certain conditions or complications considered reasonably preventable, such as wrong-side surgeries.

The OIG is interested in the number of inpatient stays associated with HACs. (Health Grades recently reported that on average, one in nine patients developed a HAC, across the nine common procedures evaluated for complications, from 2007 to 2009.) The OIG will look closely at the accuracy of coding certain conditions as “present on admission” (POA) and at providers who transfer patients to other facilities to avoid the HAC payment penalty.

Two of the OIG’s target areas relate to quality reporting systems. First, since hospitals risk receiving a negative annual update (-2%) if they do not report the required quality measures to CMS and thus have an incentive to submit whatever data they can, the accuracy and reliability of their quality data will be the subject of a new review in 2011. With respect to reporting on the adverse peri-operative events that are captured in the Surgical Care Improvement Project (SCIP) or Medicare Physician Quality Reporting Initiative (PQRI), anesthesia groups can be of considerable service and value to their hospitals. We know of some large institutions in which the anesthesia groups’ IT professionals have created such superior departmental quality management systems that they have gone on to assist the facilities in developing their own quality reporting technologies. The benefit to the anesthesiologists’ relationship with the hospital is clear. So is the benefit if the anesthesia group is able to work with its institution on the information about adverse events captured by internal incident-reporting systems, which is also a Work Plan focus.

Keeping up with the OIG’s annual issuance of its Work Plan for the next calendar year, while not the most diverting reading, is an important part of compliance. We hope that the highlights noted above will be helpful to you.

Sincerely,

Tony Mira
President and CEO



If you have any questions or would like additional information please call 517-787-6440 x 4113, send an email to info@anesthesiallc.com, or visit our website at www.anesthesiallc.com.