2016 OIG Work Plan Outpatient Issues

on Wednesday, 25 November 2015. All News Items | Outpatient Services | OIG | Billing

Analyzing the Analyzers

In our modern, electronic world, it is no surprise that Medicare entities and affiliates, such as the Medicare Administrative Contractors (MACs) and the Office of Inspector General (OIG) utilize data analysis to help find fraud, waste and abuse in the Medicare program. On the “provider” side, Medical Management Plus analyzes Medicare outpatient remittances (835s) in our HIQUP reports to assist hospitals with denial management and to identify potential losses and risks before a government entity finds them for you. Providers can determine the “high-risk” areas by being aware of the issues Medicare reviewers are targeting. One such tool for providers is the annual OIG Work Plan that lists the audit issues the OIG is planning to address in the coming year.

There are a number of issues that affect hospital outpatient departments in the 2016 OIG Work Plan.

Medicare Compliance Reviews

In these reviews, the OIG seems to look at any and all billing issues. Actually, this is where they employ data analysis to identify a hospital’s claims that are at risk of being incorrect in order to target their efforts for maximum benefit to the Medicare Trust Fund. You will also notice that some of the issues identified through these compliance reviews eventually become targeted issues of their own. Some of the outpatient issues identified in previous OIG hospital compliance reviews are: incorrect HCPCS code and/or incorrect units of service; inappropriate bundling; modifier 59 errors; and separately billed outpatient services that should be part of an inpatient stay, a home health episode or skilled nursing facility consolidated billing.

Outpatient Dental Claims

Medicare does not cover routine dental services, that is items or services related to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth. Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. The OIG will be reviewing to make sure hospitals haven’t been paid for noncovered dental services.

Right Heart Caths with Endomyocardial Biopsies

The OIG will make sure hospitals are following Medicare billing requirements for cardiac catheterizations and endomyocardial biopsies. Per the NCCI manual, “Endoymocardial biopsy requires intravascular placement of catheters into the right ventricle under fluoroscopic guidance. (Providers) should not separately report a right heart catheterization or selective vascular catheterization CPT code for placement of these catheters. A right heart catheterization CPT code may be separately reportable if it is a medically reasonable, necessary, and distinct service performed at the same or different patient encounter.”

Intensity-Modulated Radiation Therapy (IMRT)

IMRT planning services billed with CPT code 77301 include the services described by several other CPT codes whether these services are performed on the same or different dates of service. CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 may only be billed in addition to 77301 if they are not provided as part of developing the IMRT treatment plan.

Medical Device Credits

Through-out the numerous hospital compliance reviews, the OIG has consistently found where hospitals have failed to appropriately report device credits when medical devices are replaced at no cost or reduced cost of 50%or greater than the total device cost. For certain device-intensive procedures, Medicare requires hospitals to report the device credit amount on the claim using the FD value code to allow an adjusted reduced Medicare payment.

Provider-Based Status

For several years, Medicare and the OIG have been concerned about the payments hospitals are receiving for services provided in off-campus provider based departments (PBDs). These PBD payments are greater than payments for similar services made to free-standing clinics. The OIG has two issues related to provider-based status this year – one to verify if classification and billing for PBDs are correct and another to compare payments between PBDs and freestanding clinics. In separate but related news, beginning January 1, 2016, a “PO” modifier is required on all outpatient services furnished in hospital off-campus PBDs. Also, the Bipartisan Budget Act of 2015 limits payment for new (established on or after November 2, 2015) provider-based hospital outpatient departments to either payments in accordance with the Medicare Physician Fee Schedule or the Ambulatory Surgery Center PPS beginning January 1, 2017.

Sleep-Testing Procedures

High-utilization of sleep testing is driving this review that looks at payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities. The OIG is concerned about the medical necessity of these procedures; avoiding duplicate, unnecessary testing; and meeting the requirements for coverage. For example, a recent OIG audit report identified errors due to lack of supporting documentation, specifically:

  • No documentation for the face-to-face clinical evaluation, the attending physician’s orders, or the interpretation report
  • Documentation for a face-to-face clinical evaluation that was incomplete because it did not record one or more of the following requirements: patient’s sleep history and symptoms, Epworth sleepiness scale, body mass index, or neck circumference.

This should give providers plenty of outpatient issues for internal evaluation and possible investigation. At least an analysis… If you are interested in learning more about MMP’s outpatient data analysis product, the HIQUP report, please contact one of our associates. Phone numbers and contact information are available on our website at www.mmplusinc.com

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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