OIG Enforcement Actions

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It’s been a while since I’ve posted the Office of the Inspector General’s (OIG) enforcement actions.

They have been busy. Unfortunately, fraud and other alleged violations of law continue to happen.

Here are some of the actions. For the complete list, visit https://oig.hhs.gov/fraud/enforcement/

Licensed Attorney Sentenced to Prison For Defrauding Medicaid in Scheme Involving Personal Care Services

While in law school, the then law student worked as a personal care aide for an agency. The law student submitted false timesheets that resulted in false claims filed to Medicaid for services that were not performed.

Connecticut Ophthalmologist Pleads Guilty to Five-Year Health Care Fraud Scheme

The ophthalmologist received kickbacks from a medical diagnostic company for ordering hundreds of medically unnecessary brain scans.

United States Files Claims Alleging Fresenius Vascular Care, Inc. Defrauded Medicare and Other Healthcare Programs by Billing for Unnecessary Procedures Performed on Dialysis Patients

According to the complaint, the company is accused of performing medically unnecessary procedures on end-stage renal patients.

Jury Convicts Man of $600 Million Health Care Fraud, Wire Fraud, and ID Theft Scheme

The man who operated a medical billing company instructed his physician-clients to schedule elective surgeries through the emergency room, resulting in higher charges. He then submitted the claims to the payers. When payers denied the inflated charges, he presented himself as the patients to demand that the insurance companies submit payments to the providers.

Suburban Chicago Doctor Charged with Health Care Fraud in Connection with Alleged False Claims to Medicare and Private Insurer

This doctor is accused of submitting fraudulent claims that represented that he removed medically unnecessary moles and creating false documentation to support the services.

Jury Convicts Doctor of Health Care Fraud Scheme

An ENT was convicted of billing Medicare and Medicaid and receiving payments for incision procedures of the external ear when he only performed ear exams or ear wax removals.

CEO of Raleigh Healthcare Company Pleads Guilty to Multi-Million Dollar Healthcare Fraud

The CEO of two durable medical equipment companies paid companies in India and Pakistan to provide her with lists of Medicare patients’ names and identification numbers. Then, she used the patient information to submit claims to Medicare (without physicians’ orders).   She even submitted claims to Medicare for over 400 deceased individuals. Then, when Medicare contractors audited her, she forged physicians’ orders to support her fraudulent claims.

New Orleans Woman Charged with Health Care Fraud

A Denial Specialist is accused of creating false patient accounts and insurance EOBs and making it appear that patients paid out of pocket. In addition, the Denial Specialist is charged with initiating refunds to patients and having the refund checks deposited into her bank account.

“All money ain’t good money.”

2023 Evaluation and Management Services Updates

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There are many additions and updates to the CPT E/M guidelines and here is a link to the 2023 CPT E/M Descriptors and Guidelines.

If you are coding and/or auditing evaluation and management services, you really should print the AMA document and keep it handy.

These critical updates/revisions are effective as of January 1, 2023. 

If you work for or contract with a computer-assisted coding or an encoder vendor, make sure they are updating and testing their systems now.

Deleted Codes:

• Observation Care Discharge Services (99217)
As of January 1, 2023, assign Hospital Discharge Services 99238 or 99239 for observation care discharge services
• Initial Observation Care (99218-99220)
As of January 1, 2023, assign Initial Hospital Care 99221-99223 for initial observation care
• Subsequent Observation Care (99224-99226)
As of January 1, 2023, assign Subsequent Hospital Care 99231-99233 for initial observation care
• Office or Other Outpatient Consultations (99241)
As of January 1, 2023, assign 99242-99245
• Inpatient or Observation Consultations (99251)
As of January 1, 2023, assign 99252-99255
• Other Nursing Facility Services (99318)
As of January 1, 2023, assign 99307-99310
• Domiciliary, Rest Home, or Custodial Care Services – New Patient (99324-99328)
• Domiciliary, Rest Home, or Custodial Care Services – Established Patient (99334-99337)
As of January 1, 2023, assign 99341, 99342, 99344, or 99345 (new patient)
As of January 1, 2023, assign 99347-99350 (established patient)
• Domiciliary, Rest Home, or Home Care Plan Oversight Services (99339, 99340)
As of January 1, 2023, assign 99347, 99491 or 99424, 99425
• Prolonged Services – Outpatient (99354, 99355)
As of January 1, 2023, assign 99417
• Prolonged Services – Inpatient, Observation, or Nursing Facility (99356, 99357)
As of January 1, 2023, assign 993X0

New Code:
• 993X0
This is a new add-on code for 2023 to report prolonged service time for inpatient or observation with or without direct patient contact. This code is to be reported in addition to 99223, 99233, 99236, 99255, 99306, and 99310.

Revised Codes Descriptions:

The following categories are revised to align with the 2021 code structure for office visits.

Effective as of January 1, 2023, these categories will only require a medically appropriate history and/or examination. The E/M level will be assigned based upon the level of Medical Decision Making or Time except for Emergency Department Services where time is not a factor.

Note the 2023 changes in Time for each E/M level!

• Initial Hospital Inpatient or Observation Care (99221-99223)
99221 – 40 minutes
99222 – 55 minutes
99223 – 75 minutes
Services 90 minutes or longer, use prolonged services codes

• Subsequent Hospital Inpatient or Observation Care (99231-99233)
99231 – 25 minutes
99232 – 35 minutes
99233 – 50 minutes
Services 65 minutes or longer, use prolonged services codes

• Hospital Inpatient or Observation Care Services – Including Admission and Discharge Services (99234-99236)
99234 – 45 minutes
99235 – 75 minutes
99236 – 85 minutes
Services 100 minutes or longer, use prolonged services codes

• Office or Other Outpatient Consultations
99242 – 20 minutes
99243 – 30 minutes
99244 – 40 minutes
99245 – 55 minutes
Services 70 minutes or longer, use prolonged services code 99417

• Inpatient or Observation Consultations
99252 – 35 minutes
99253 – 45 minutes
99254 – 60 minutes
99255 – 80 minutes
Services 95 minutes or longer, use prolonged services codes

• Initial Nursing Facility Care
99304 – 25 minutes
99305 – 35 minutes
99306 – 45 minutes
Services 60 minutes or longer, use prolonged services codes

• Subsequent Nursing Facility Care
99307 – 10 minutes
99308 – 15 minutes
99309 – 30 minutes
99310 – 45 minutes
Services 60 minutes or longer, use prolonged services codes

• Home or Residence Services – New Patient
99341 – 15 minutes
99342 – 30 minutes
99343 – This code is not listed in the updates as deleted or revised. Stay tuned for the Addendum
99344 – 60 minutes
99345 – 75 minutes
Services 90 minutes or longer, use prolonged services code 99417

• Home or Residence Services – Established Patient
99347 – 20 minutes
99348 – 30 minutes
99349 – 40 minutes
99350 – 60 minutes
Services 75 minutes or longer, use prolonged services code 99417

• Emergency Department Services (99281-99285)
Time is NOT a descriptive component for services in the Emergency Department. The overall level of E/M services will be based upon the level of Medical Decision Making.

Effective January 1, 2023, some of the descriptors for the levels of Medical Decision Making will be revised:
99281 – was Straightforward MDM. For 2023, the descriptor is “may not require the presence of a physician or other qualified health care professional”
99282 – was Low complexity MDM. For 2023, the descriptor is Straightforward MDM
99283 – was Moderate MDM. For 2023, the descriptor is Low MDM
99284 – was and will remain Moderate MDM for 2023
99285 – was and will remain High MDM for 2023

2023 ICD-10-CM Updates – ICD-10-CM Codes Updates

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I’m still sipping my Starbucks® Bottled Caramel Frappuccino® Coffee Drink, so let’s jump right into the ICD-10-CM codes updates.

Summary:

Except for the increase from 14,000 to approximately 68,000 in 2016, FY 2023 marks the second largest number of code changes since the implementation of ICD-10-CM.

The 2023 updates include 1,176 new codes, 28 revised codes, 287 deleted codes, and numerous changes to Includes and Excludes notes.

Here’s the link to the 2023 Addendum that lists all of the additions, deletions, revisions, and updates for Inclusions and Exclusions for your review.

• To access the ICD-10-CM TABULAR LIST of DISEASES and INJURIES 2023 Addenda, select 2023 Addendum (ZIP), open the ZIP file, and select icd10cm tabular addenda 2023.

To put the number of changes for 2023 in perspective, here are the numbers from previous years:

FY 2022

159 new codes, 20 revised codes, and 32 deleted ICD-10-CM codes.

FY 2021

490 new codes, 47 revised codes, and 58 deleted ICD-10-CM codes.

FY 2020

273 new codes, 30 revised codes, and 21 deleted ICD-10-CM codes.

FY 2019

279 new codes, 143 revised codes, and 51 deleted ICD-10-CM codes.

FY 2018

360 new codes, 226 revised codes, and 142 deleted ICD-10-CM codes.

FY 2017

1,974 new codes, 425 revised codes, and 311 deleted ICD-10-CM codes.