Month: October 2021

OIG Work Plan

Featured Coffee – Frankenbones

It’s been a while since I’ve reviewed the updates to the OIG Workplan.

Lots of audits are planned for 2022.  Are you prepared?

In  OIG 2020 Active Work Plan Items, I highlighted some items from the workplan that presented opportunities to be proactive in assessing your risk for an audit, providing education to your providers and coding staff, and creating compliance plans for more focused audits.

Let’s review some of the OIG audits, evaluations, and inspections that are underway or planned. 

Report W-00-21-35876:  Audit of Medicare Part B Opioid-Use-Disorder Treatment Services Provided by Opioid Treatment Programs

The expected issue date is 2023.

This review will focus on opioid use disorder (OUD) treatment services for Medicare beneficiaries in nonresidential opioid treatment programs (OTPs) to determine whether the services were allowable according to Medicare requirements.

CMS has an MLN fact sheet that provides education for Opioid Treatment Program (OTP) providers and institutions about Medicare billing and payment for Opioid Use Disorder (OUD) treatment services.

Report W-00-21-35877; W-00-22-35877:  Audit of Medicare Emergency Department Evaluation and Management Services

The expected issue date is 2022.

This review will determine whether emergency department evaluation and management services were appropriate, medically necessary, and comply with Medicare requirements.   

Here’s a link to CMS evaluation and management guidelines. 

Report W-00-21-35872;  W-00-22-35872:  Accuracy of Place-of-Service Codes on Claims for Medicare Part B Physician Services When Beneficiaries Are Inpatients Under Part A

The expected issue date is 2022.

This review will “determine whether Medicare appropriately paid claims for Part B physician services based on the correct place-of-service code when a beneficiary was an inpatient at a SNF or hospital.”

Report W-00-21-35825; W-00-22-35825:  Audits of Medicare Payments for Spinal Pain Management Services

The expected issue date is 2022.

This audit will determine “whether Medicare payments for spinal pain management services billed by physicians complied with Federal requirements.”

Check LCDs and NCDs.

Report W-00-21-35868:  Dermatologist Claims for Evaluation and Management Services on the Same Day as Minor Surgical Procedures

The expected issue date is 2022.

This review will “determine whether dermatologists’ claims for E/M services on the same day of service as a minor surgical procedure complied with Medicare requirements.”

Watch the 25 modifier!

 Of course, there are many more items on the OIG Work Plan than I’ve listed here. 

Stay up to date and continue your internal audits and provider education.

K

Don’t Rush the Process

Featured Coffee – Cinnamon Streusel Coffee Cake Coffee

Here’s a question that I received:

“I’m only halfway through my course, and my exam is scheduled in less than a month.  Do I have to complete the course before I can sit for the certification exam?”

This was my response, and yes, it was tough love.

If you do not have coding experience, why would you want to sit for the certification exam before you complete the course?

Are you not taking medical coding seriously?  Do you think it’s that easy to code that you don’t need to complete the course?

Do you fully understand the responsibility and liability placed on medical coders?

In my post, So, You Want To Be a Coder, I asked the questions, “Do you have analytical skills?  Are you willing to take the time to learn coding guidelines?  Are you prepared to research?  Are you comfortable working independently and being subjected to frequent interruptions that require immediate responses?  Do you have advanced knowledge of medical terminology, abbreviations, techniques and surgical procedures, anatomy and physiology, major disease processes, pharmacology, and the metric system?”

You may pass the test without completing the course.  You have a one in three chance of “selecting” the correct answer to each question, and you only need a 70% score.

In the real world, you don’t have multiple-choice answers. Instead, you are translating the documentation into codes based on coding guidelines.

By the way, most companies require at least 95% accuracy on your coding audits for you to keep your job.

How committed will you be as a coder if you can’t commit to learning how to code?

If, without any coding experience, you think you already know enough to pass the certification exam, how open will you be to learning on the job?

If you think you know it all, I always tell coders to get out of the industry because you’re a risk to your providers. 

In this industry, we are constantly learning new rules, processes, and general and payer-specific guidelines. 

So, based upon your question, this is how I see you:

  • You either don’t know or don’t respect the complexity of medical coding. 

Are you fluent in the language of medical coding?  Are you ready to read an operative report and translate it into codes?  Are you comfortable interpreting how the coding guidelines apply to that document?

  • You’re not aware of the impact that your coding has on patients, hospitals, or practices. 

The codes you assign are submitted to payers for reimbursement, other health statistics agencies, and other providers for continuity of care for the patients.

If you’re submitting incorrect codes, it can result in audits, fines, or other penalties for the hospital or provider. 

Your incorrect codes can result in incorrect data for health statistics.

If you don’t have the time or motivation to learn how to code, and you’re rushing through the process, why do you think you should sit for the exam? 

If you are serious about becoming a medical coder and taking on all of the responsibilities, why not take responsibility and request/pay for an extension?

Reader’s Question – Z-Series or S-Series

Featured Coffee – Autumn Spice

Linda sent this scenario. 

If you have a question, send me an email at diaryofamedicalcodingauditor@gmail.com.

Our Radiologists only document trauma or injury in the clinical indication, and the final diagnosis shows no acute findings.

Some coders report as Z04-3 – and others report as an injury to the body area being studied (S-series).

Who is correct?  Please cite sources that I can share with my team.

This was my response:

The coders assigning Z04.3 are correct, and here are the sources:

Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

6) Observation

“There are three observation Z code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code.”

So, Linda, even though the provider documented “injury” as the reason for the study, the provider did not diagnose/confirm an injury in the impression – an injury was not found.

Here’s a Coding Clinic that is your exact scenario. Although it’s from 2006, it is still applicable.

According to AHA Coding Clinic, December 2015:

In general, clinical information and information on documentation best practices published in Coding Clinic were not unique to ICD-9-CM, and remain applicable to ICD-10-CM with some caveats. For example, Coding Clinic may still be useful to understand clinical clues when applying the guideline regarding not coding separately signs and symptoms that are integral to a condition. Users may continue to use that information, as clues—not clinical criteria.

As far as previously published advice on documentation is concerned, documentation issues would generally not be unique to ICD-9-CM, and so long as there is nothing new published in Coding Clinic for ICD-10-CM and ICD-10-PCS to replace it, the advice would stand.

  • ICD-9-CM Coding Clinic, First Quarter 2006 Page:  9 Effective with discharges:  May 12, 2006

CT scan following trauma

“Trauma is not always indicative of injury.”

Therefore, it would not be appropriate to assign a diagnosis from the S-series when the provider did not document an injury.

These are additional clarifications from Coding Clinic:

  • ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2019 Page: 11 Effective with discharges: June 21, 2019

Pregnancy with observation following motor vehicle accident

  • ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2018 Pages: 7-8 Effective with discharges: June 6, 2018

Observation for suspected burn injury

  • ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2018 Page: 8 Effective with discharges: June 6, 2018

Observation for suspected injury following motor vehicle accident

  • ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2018 Page: 8 Effective with discharges: June 6, 2018

Observation for suspected injury following motor vehicle accident

  • ICD-9-CM Coding Clinic, March – April 1987 Page:  1 to 5

Observation and evaluation for suspected conditions – guidelines