
Be Aware — Emergency Department Visits Under OIG Scrutiny
June 20th, 2023 - Wyn Staheli
Every year the Department of Health & Human Services Office of Inspector General (OIG) creates an official work plan giving everyone a heads up as to what they are going to be reviewing. The 2022 Work Plan stated that they would be reviewing claims for Evaluation & Management services provided in an emergency department (ED) setting because previous audits identified problem areas. The 2022 Medicare Fee-for-Service Improper Payment Report showed a 13.5% error rate with 21.4% of those related to “insufficient documentation” and 65.5% for “improper coding.”
According to the OIG Work Plan (emphasis added):
“An emergency department is defined as an organized, hospital-based facility for providing unscheduled or episodic services to patients who present for immediate medical attention. Certain Current Procedural Terminology (CPT) codes should only be used when a beneficiary is seen in an emergency department and the services described by the health care CPT coding system code definition are provided. Medicare reimburses physicians based on a patient's documented needs at the time of a visit. All evaluation and management (E/M) services reported to Medicare must be adequately documented so that medical necessity is clearly evident. This review will determine whether Medicare payments to providers for emergency department E/M services were appropriate, medically necessary, and paid in accordance with Medicare requirements.”
As noted above, one of the key review issues is whether or not the E/M service is “adequately documented so that medical necessity is clearly evident.” Therefore, it is crucial to understand both E/M service level requirements as well as what is considered “medically necessary” in order to appropriately document the encounter.
This will get a little tricky since the codes for these services changed January 1, 2023. Although some of the rules for CPT code level selection may have changed, what CMS considers medically necessary has not changed. Join us on Thursday, June 22, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. for a free webinar covering these important topics.
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)
Reporting Drug Wastage with Modifier JW and NEW Modifier JZAugust 15th, 2023 - Aimee WilcoxModifier JW has been around since 2003 with changes in Medicare policies to ensure standard utilization in 2017; however, because of a continued lack of reporting consistency, Medicare has created and implemented policy related to reporting a new modifier, JZ. How does this impact Medicare reimbursement and why is this modifier so important?
Finding Patterns of Complexity in the Medical Decision Making (MDM) Table August 8th, 2023 - Aimee WilcoxChanges to the Medical Decision Making (MDM) Table in 2023 reflect the work performed in the facility setting in addition to the work involved in Evaluation and Management (E/M) scoring in other places of service. Taking the time to really look closely at the MDM Table and identify patterns in wording and scoring helps coders to understand scoring in an easier way.
Seven Reasons to Standardize Medical RecordsJuly 18th, 2023 - Aimee WilcoxThe standardization of medical records offers numerous benefits for healthcare systems, providers, and patients. By ensuring interoperability, improved workflows, better patient safety, supporting research endeavors, and optimizing resource allocation, standardized records contribute to improved efficiency, quality of care and especially patient outcomes. Here are seven reasons to standardize medical records.
Advancements in Coding Hospital Observation Care Services in 2023July 4th, 2023 - Aimee WilcoxHospitals are increasingly adopting innovative solutions to improve patient care and optimize processes and many of these solutions follow immediately the recent CPT and Medicare coding changes. In 2023 coding of hospital observation care services underwent significant changes enabling healthcare providers to accurately document and bill for the sick or injured patient that requires a higher level of medical services between the emergency room care and hospital admission. This article explores the key changes in coding hospital observation care services and their impact on healthcare delivery.
Be Aware — Emergency Department Visits Under OIG ScrutinyJune 20th, 2023 - Wyn StaheliEvery year the Department of Health & Human Services Office of Inspector General (OIG) creates an official work plan giving everyone a heads up as to what they are going to be reviewing. The 2022 Work Plan stated that they would be reviewing claims for Evaluation & Management services provided in an emergency department (ED) setting.
OIG Audit Reveals Diagnosis Reporting Problems Affecting Risk Adjustment ScoringJune 15th, 2023 - Wyn StaheliThe Office of the Inspector General (OIG) recently published their Spring 2023 Semiannual Report to Congress. This report contained some diagnoses reporting issues that all providers need to be aware of. They focused on several groups of diagnoses that they considered “High-Risk” for being miscoded. Several states were included in the report and the types of errors for all can be generally grouped into several categories.
Documenting for Suture and Staple Removal E/M Add-On CodesMay 30th, 2023 - Aimee WilcoxHistorically, the 10-day and 90-day global periods would include the patient's follow-up Evaluation and Management (E/M) services and any dressing changes or staple/suture removal related to the surgery; however, following a closer analysis of these and other surgery codes, the decision was made to make significant revisions to these codes to ensure proper reporting.