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The Inspector General’s 2016 Plan to fight fraud, waste, and abuse in Medicare and Medicaid programs

The Office of Inspector General (OIG) is the arm of the US Department of Health and Human Services that fights fraud, waste and abuse in the Medicare and Medicaid programs. Each year, the OIG publishes it fiscal year “Work Plan” which highlights its areas of focus for hospitals, nursing homes, and other providers. There is a link to the OIG Work Plan at the end of this article.

The 2016 Work Plan has two project areas that relate to physician billing which are new for this year.

First, the OIG will be investigating the reasonableness of prolonged services. CPT® describes the prolonged services codes as follows:

  • 99354: Prolonged evaluation and management…(beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service first hour
    • 99355: Each additional 30 minutes (add on)
  • 99356: Prolonged service n the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour
    • 99357: Each additional 30 minutes (add on)

These codes would be reported in addition to your “base” E&M code when appropriate. As you know, these codes have been on pre-payment audit by our local Medicare Administrative Contractor, National Government Services, for quite some time. The most recent results, from March 2016, indicate that 85% of the services were reduced or denied upon review of the medical record documentation. The most common errors were:

  • Direct face-to-face or floor/unit time was not supported
  • Lack of content of prolonged service needed beyond usual E&M
  • Code reported for family meeting without patient in attendance
  • Documentation was missing a date (dictation date not sufficient to support a record)

The second new project area in this year’s OIG Work Plan is the reasonableness of home visits. Medicare has paid $559 million in payments for home visits since January of 2013, a large increase from previous years. Medicare only covers services that are “reasonable and necessary” and will be reviewing medical records to ensure that the medical necessity of the home visit is documented. The criteria for home visits are:

  • Criteria #1 (must have one or the other):
    • Illness or injury requires the assistance of supportive devices or another person in order to leave the residence
    • Have a condition for which leaving the residence is medically contraindicated
  • Criteria #2 (must have both)
    • There must exist a normal inability to leave home
    • Leaving home must require a considerable and taxing effort

Furthermore, CMS issued a clarification stating “The aged person who does not often travel from home because of feebleness and insecurity brought on by advanced age would not be considered confined to the home” unless the above criteria are met.

As you can see, the OIG and HHS are closely scrutinizing the “reasonableness” of services provided by reviewing documentation from your medical records. The importance of explicitly describing the medical necessity of the services you bill simply can not be overstated.

Link to OIG Work Plan: http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf

Sources: Medicare Claims Processing Manual, MM8818, www.ngsmedicare.com