Medical imaging under the Office of the Inspector General's watchful eye in 2013

A growing concern of many health care providers is an increasingly complex regulatory environment, and a common approach is to “know enough just to stay out of trouble.” Urologists are at risk for financial penalties or worse if they do not keep current in this regard. In a series of three articles, I examine the Office of the Inspector General (OIG), explain its relevance to urologists and their practice, and provide practical tips to understand and manage any risks associated with the activities of this institution. In this second installment, I explore additional details of the OIG’s 2013 work plan, focusing on areas that have particular relevance to a urologist and his/her practice.

As I noted in the first installment in this series (“The OIG: What you don’t know can hurt you,” March 2013, page 26), the OIG telegraphs its areas of focus and attention each year in its “Work Plan,” providing an opportunity to do a risk assessment for your practice. (To view the fiscal year 2013 work plan, see https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.) Here are some areas of focus from the OIG’s 2013 work plan that might affect a urology practice, its physicians, and patients.

Part B imaging services-payment for practice expenses. Practices that bill Medicare for imaging services take note: According to the 2013 work plan, the OIG will examine facility Part B payments to be sure “practice expenses incurred and… utilization rates reflect industry practices.” In this context, practice expenses include rent, wages, and equipment costs. It seems reasonable to assume that the Centers for Medicare & Medicaid Services can measure “utilization” of imaging services in its large data set, and that the OIG might focus on outliers. While neither CMS nor the OIG has published the exact methodology for “utilization” or national benchmarks, such metrics are usually founded in per-patient, per-physician, or per-episode-of-care denominators. A urology practice with in-house imaging might wish to examine ordering, referral, and volume patterns to look for patterns and exceptions to those patterns.

Medical necessity of imaging. In a related area, the OIG has signaled its intention to focus on the medical necessity of high-cost imaging studies and “the extent to which the same diagnostic tests are ordered… by primary care physicians and physician specialists for the same treatment.” Determination of medical necessity is a challenging subject that spans a number of documents and processes, including the Medicare Coverage Manual, National Coverage Determinations (NCD), Local Coverage Determinations (when an NCD does not exist or needs clarification), and, when needed, external technical assessments or reviews by the Medicare Evidence Development & Coverage Committee.

High-cost imaging tests are often duplicated in health care settings-including urology practices-because the original study is either not available or of insufficient quality for important decision making. Urologists would be well advised to carefully document the reason for repeating a high-cost diagnostic radiology test, especially if they are also billing CMS for the service. Practice staff accustomed to securing predetermination of benefits or precertification for high-cost imaging from commercial insurance companies could be a valuable resource to help identify just what the OIG might look for in determining medical necessity. For more detail on determining medical necessity in the Medicare program, see the Medicare Coverage Database (www.cms.gov/medicare-coverage-database/ and http://cms.gov/Medicare/Coverage/DeterminationProcess/index.html).

Incident to services performed by non-physicians. On another front, the OIG seems interested in the error rate for services performed by non-physicians “incident to” a physician office visit, and in fact states that such services “may be subject to overutilization and expose beneficiaries to care that does not meet professional standards of quality.”

The adoption of advanced practice practitioners in urology practices has resulted in much efficiency for patients and their providers, and Medicare reimbursement rules incentivize urologists to bill under the incident to rules (the urologist’s billing credentials and direct supervision by the urologist) for those services. This increase in productivity appears as an increase in utilization for the urologist and may put him squarely on the radar of the OIG. Incident to services cannot be discerned from claims data, and practices investigated by the OIG for this reason could see a number of requests for medical records-and the administrative burden entailed therein. Be sure you understand the rules governing incident to services and are abiding by them. For more, see Medicare benefit policy Manual Chapter 15 - Covered Medical and Other Health Services, transmittals 60.1, 60.2, 60.3 (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf).

Place of service coding errors. The OIG will review place of service errors. Medicare generally pays a physician a higher rate for the same procedure when it is performed in an office setting versus a non-office setting. Urology practices that commonly perform prostate biopsy, cystoscopy, vasectomy, and other procedures in ambulatory surgery centers and hospitals should review their processes for ensuring that the correct place of service code is attached-and specifically that the place of service code 11 (physician office), which would generally raise the reimbursement for the procedure, is not attached in error.

Use of modifiers during the global period. The appropriateness of evaluation and management service modifiers during the global period is under the OIG microscope. As surgical specialists, urologists are generally aware that Medicare has defined a reimbursement concept called the “global surgical package;” each surgical procedure code is accompanied by a global period during which Medicare will not pay for E&M services they consider included in the package. Modifiers can be appended to indicate exceptions to or special circumstances about the global period, and the OIG believes this is another area that is vulnerable to inappropriate payments. For an excellent summary of the rules for global periods and the use of modifiers during the global period, see the CMS Global Surgery Fact Sheet (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf).

Bottom line: Our nation’s largest health care insurer-the federal government-has put in place people and processes to monitor the integrity of the federal health care program. Urologists should be familiar with the rules and the areas of focus and scrutiny of oversight agencies like the OIG. In the third installment of this series, I will cover other areas on the OIG radar including payments for expensive drugs and E&M services involving “identical documentation."UT