Health Information Management

Compliance hinges on understanding the reviews

HIM-HIPAA Insider, June 2, 2014

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In FY 2014, the OIG is setting out to review some aspects of billing and payments that were not included in the prior Work Plan. It should come as no surprise that the FY 2014 OIG Work Plan includes reviews of Medicare outpatient hospital payments for E/M services for visits billed at the new rate set forth by the 2014 OPPS final rule. Providers and HIM professionals must pay particular attention to these codes just as OIG continues to focus on reviewing them.

"The goal of HIM professionals is to make sure that the documentation in the health record can justify the service level coded," says Anita Hazelwood, RHIA, FAHIMA, an HIM professor at the University of Louisiana at Lafayette. "In general, physicians are definitely providing the billed level of service but not doing as good a job with documenting what was done."
Hospitals should audit E/M data from past years to determine risk in this area, says Debbie Mackaman, RHIA, CPCO, a regulatory specialist at HCPro in Danvers, Massachusetts. Although most hospitals will bill using one E/M code for their clinic visits (G0463), the OIG is interested in recouping overpayments from prior years. Reviewing the way your hospital defined new and established patients before calendar year 2014 is a good idea. "Hospitals who did not apply the definition correctly in the previous years may have been over- or underpaid," Hazelwood adds.
The OIG will begin reviewing the following:
  • Medicare payments for right heart catheterizations and heart biopsies billed during the same operative session
  • Medicare hospital payments for claims that include a diagnosis of kwashiorkor to determine whether the record supports the diagnosis
  • Medicare hospital payments for bone marrow or peripheral blood stem cell transplantation
  • Indirect medical education payments
Continue reading "Compliance hinges on understanding the reviews" on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the June issue.

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