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OIG releases 2011 Work Plan: EMTALA out, radiation therapy and medical devices in

HCPRO Website, October 4, 2010

by Michael Iarrobino, CPC-A

Medical devices, radiation therapy quality and safety, and an expanded focus on the three- and one-day payment windows are among the highlights of the Office of Inspector General's (OIG) fiscal year (FY) 2011 Work Plan. The Work Plan, posted October 1, introduces some new focus areas but largely continues the OIG's stance from 2010.

"What we're really looking at are four or five really brand new issues," says Stephen Miller, JD, chief compliance and privacy officer for Trenton, NJ-based Capital Health System, Inc. This should make the work easier for hospital compliance officers, who often target new topics as ones for which they must develop additional auditing tools and strategies.

New topics address quality, billing concerns
Among entrants to the OIG list for 2011, Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., in Marblehead, MA, highlights the following:

  • Brachytherapy reimbursement
  • Replacement of devices received at no cost or reduced cost
  • Safety and quality of intensity-modulated radiation therapy (IMRT)
  • Safety and quality of image-guided radiation therapy (IGRT)

"Any time the OIG adds new issues, such as medical devices, brachytherapy, IMRT and IGRT, facilities who provide these services should sit up and take notice," Mackaman says.

Miller notes the focus on quality and safety with IMRT and IGRT. Their inclusion on the list shows the OIG's responsiveness to the headlines, he says. Media reports circulated earlier this year in outlets such as The New York Times regarding quality concerns with these types of procedures, especially in connection with Veterans Affairs facilities.

From a billing perspective, Mackaman flags medical device replacement as an area for hospital attention. "Since the medical devices replacement issue can be a difficult billing procedure to comply with, facilities should certainly do an in-depth process audit in this area," she says. For information regarding proper reporting of reduced- or no-cost devices, Mackaman suggests reviewing 73 Federal Register 68631-68632 and the Medicare Claims Processing Manual, Chapter 4, sections 61.3.1-61.3.3.

This year's Work Plan omits previous stalwarts like the Emergency Medical Treatment and Labor Act (EMTALA) and coding and documentation under the MS-DRG system. In the case of EMTALA, Miller says, the OIG may believe that CMS is sufficiently scrutinizing hospitals.

Payment window attention goes beyond IPPS
Among hot-button issues on the OIG focus list is the three-day rule, which this past year has seen legislative changes and additional guidance from CMS. Medicare does not make separate payments for outpatient diagnostic services and admission-related nondiagnostic services rendered up to three days before the date of an inpatient admission. In June, Congress passed and President Obama signed legislation to change these rules and redefine services that are related to the admission. Many hospitals had struggled to apply the previous rules correctly.

Although last year's Work Plan also saw a focus on the three-day rule, this year the OIG expanded its scope to include the one-day payment window applicable to non-IPPS facilities, notes Mackaman. Payments to these non-IPPS hospitals for inpatient claims should include diagnostic services and other services related to admission provided the day immediately preceding the date of the patient's admission.

"IPPS facilities should be vigilant about reviewing the current three-day rule, and the non-IPPS hospitals should review the addition of the one-day rule," Mackaman says.

Provider-based status remains in focus
Provider-based status is another repeat item on the OIG list. In response to the continued attention, hospitals should review the provider-based requirements located at 42 CFR § 413.65(d).

"Hospitals should make sure they are meeting the regulations for billing for hospital outpatient services correctly under the designation of either on-campus or off-campus provider-based departments," Mackaman says. "This would include the rules for billing for services under incident to and direct supervision," she adds.

OIG renews attention to observation, other topics
Those perusing this year's Work Plan will find plenty of continuity with the FY 2010 edition. Observation services provided as part of an outpatient visit, for example, appear in both documents. But that doesn't mean compliance officers can let down their guard.

"This area is extremely difficult to manage," Miller says. "It should probably be higher on the list for auditing."

The continued attention to observation may come, in part, due to the increased use of these services as hospitals find themselves pushed by CMS and audited by the recovery audit contractors to ensure medical necessity for inpatient stays.

Other topics marked as works in progress include the following:

  • Part A hospital capital payment
  • Critical access hospitals
  • Medicare disproportionate share payments
  • Duplicate graduate medical education payments
  • Hospital readmissions
  • Hospital admissions with conditions coded present-on-admission
  • Inpatient rehabilitation facility transmission of patient assessment instruments
  • Medicare excessive payments

"When the Work Plans mimic themselves from year to year, it does make it a little easier for facilities to review and respond to OIG areas of interest," Mackaman says. "If the facility had reviewed an issue and did an internal audit to identify any weak areas, they should have already been working on improving their compliance in that area."

But previous audits should not preclude additional work in any of the OIG-identified areas. "If the facility did not find any problem with that area, this does not mean the facility should ignore it this year. It would be a good idea for them to audit again to make sure they are still in compliance with the area," Mackaman explains.

Editor's note: Access the FY 2011 OIG Work Plan at http://oig.hhs.gov/publications/workplan/2011/.

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