For many years, this author has written about the importance of reviewing (1) topics of scheduled audits and (2) reports of findings from completed audits. Most of the Medicare compliance audit contractors (such as the Office of Inspector General [OIG] and the Comprehensive Error Rate Testing contractor) regularly publish their planned audit topics and findings. In fact, the OIG Office of Audit Services updates and publishes their audit work plan every month. The OIG also publishes very comprehensive audit reports including:

* Why the audit was performed

* The objectives of the audit

* A background reviewing the Medicare payment program requirements and results of previous audits

* How the audit was conducted

* Findings of the audit

* OIG recommendations

* Comments from the CMS and the OIG response

* Appendices such as audit scope and methodology, specific facilities/providers that were audited, specific types of claims at high risk for incorrect billing, mathematical calculation methodology, results of appeals, detailed criteria used to evaluate claims, results of audit by risk areas, and a copy of CMS responses.

In a recent OIG audit report entitled CMS Can Use OIG Audit Reports to Improve Its Oversight of Hospital Compliance,1 the OIG reported that CMS did not always follow up on overpayment recovery recommendations in OIG audit reports and did not consistently track high-risk claims identified in OIG audits. After auditing both inpatient and outpatient claims, the OIG encouraged CMS to pay attention to its audit reports. This author is particularly concerned about four types of outpatient department errors identified in this report. All hospital-owned outpatient wound/ulcer management provider-based departments as well as wound/ulcer management physicians and other qualified healthcare professionals (QHPs) should carefully read about these errors and conduct internal audits to ensure their coding and claims align with regulations and guidelines. Conducting internal audits and implementing needed compliance changes will help prevent claims denials and repayments.

Incorrect HCPCS Codes

The OIG audit report found that 56% of outpatient claims included HCPCS codes that were not supported by documentation in the medical records. Following are some incorrect codes that this author often identifies when consulting with wound/ulcer management providers:

* Reporting multiple units of base codes when add-on codes should have been reported, such as surgical debridement (11042-11044), cellular and/or tissue-based product (CTP) application (15271, 15273, 15275, 15277), and selective debridement (97597)

* Reporting surgical debridement (11042-11044) when selective debridement (97597) was performed

* Reporting surgical debridement (11042) when paring or cutting of benign hyperkeratotic lesions such as corns or calluses (11055-11057) was performed

INCORRECT BYPASS MODIFIERS

The OIG audit report found that 31% of the outpatient departments' claims were reported with modifiers that did not align with modifier definitions and/or with National Correct Coding Initiative edit regulations. Therefore, the outpatient departments received payments that were not allowable. Some of the claims were appealed, but documentation for only 6% of the claims could prove that the modifiers were justified. The following are some incorrect uses of modifiers that this author often identifies:

* Reporting clinic visits (G0463) and evaluation and management (E/M) services (99202-99215) with modifier 25 (significant, separately identifiable E/M service by the same physician or other QHP on the same day of the procedure or other service) during the same encounter when minor procedures were performed, but significant identifiable clinic visits or E/M services were not managed

* Reporting modifier 59 (distinct procedural service) or modifier XS (separate structure) when two procedures were performed on the same anatomic location, such as surgical debridement (11042-11044) with application of total contact cast (29445), application of Unna boot (29580), application of multilayer compression bandage (29581), and low-frequency nonthermal ultrasound (97610); CTP application (15271, 15273, 15275, 15277) with surgical debridement (11042-11044), total contact cast (29445), Unna boot (29580), multilayer compression bandage (29581), selective debridement (97597-97598), negative-pressure wound therapy (NPWT) durable medical equipment (97605-97606), and disposable NPWT (97607-97608); or selective debridement (97597-97598) with application of total contact cast (29445), Unna boot (29580), multilayer compression bandage (29581), nonselective debridement (97602), NPWT durable medical equipment (97605-97606), disposable NPWT (97607-97608), and low-frequency nonthermal ultrasound (97610).

INCORRECT NUMBER OF UNITS

Consider code descriptions, payment regulations, and coverage guidelines when reporting units. The OIG audit found that 7% of the outpatient department claims incorrectly reported multiple units of procedures when one unit should have been reported. The following are some examples of incorrectly reported units:

* Reporting a unit of one for CTPs. The number of square centimeters purchased for the application should be reported with the appropriate HCPCS "Q" or "A" codes; CTPs should not be reported "per each."

* Reporting base code procedures (such as surgical debridement [11042-11044], application of CTPs [15271, 15273, 15275, 15277], and selective debridement [97597]) with multiple units, when only one unit should be reported per the code description

* Reporting clinic visits (G0463) or E/M visits (99202-99215) with multiple units

* Reporting multiple units of hyperbaric oxygen therapy supervision (99183) by physicians/QHPs when only one unit should be reported per the code description

INCORRECT SNF CONSOLIDATED BILLING

The OIG audit report also reminds providers that skilled nursing facilities (SNFs) are responsible for billing Medicare for most services, including outpatient hospital services, provided to SNF residents during their Part A-covered SNF stays. Therefore, providers should bill the SNFs, rather than Medicare Part B, for services that are included in consolidated billing. The audit found that 6% of the outpatient department claims were incorrectly billed for services that were subject to the SNF consolidated billing requirement.

When the patient is in a Medicare Part A-covered SNF stay, the providers should not bill these services to Medicare Part B:

* Application of Unna boot (29580)

* Application of multilayer compression bandage (29581)

* Selective debridement (97597-97598)

* Nonselective debridement (97602)

* NPWT durable medical equipment (97605-97606)

* Disposable NPWT (97607-97608)

* Low-frequency nonthermal ultrasound (97610)

* Hyperbaric oxygen therapy (G0277)

When the patient is in a Medicare Part B-noncovered SNF stay, the providers should not bill these services to Medicare Part B:

* Application of Unna boot (29580)

* Application of multilayer compression bandage (29581)

* Selective debridement (97597-97598)

* Nonselective debridement (97602)

* NPWT durable medical equipment (97605-97606)

SUMMARY

Readers should note that these four error types were identified in a single OIG audit. The OIG has conducted audits and written reports about many other errors pertinent to wound/ulcer management providers. Stakeholders should review the OIG reports of pertinent past audits, announcements of current audits, and monthly OIG Work Plan updates announcing future audit topics. If any topics appear to be high-risk and/or high revenue generating to readers' businesses, conduct internal audits on those topics.

Once each internal audit is complete, share the results with all the providers, coders, billers, and any other members of the revenue cycle team who impact that audit topic. Recognize and congratulate specific team members who contributed to positive audit findings and educate those who contributed to negative audit findings. All team members should be enlisted to identify processes that need to be corrected. Together, determine the exact team member(s) who will be responsible for making specific corrections and the timeline to achieve all corrections. Once the deadline for corrections has passed, conduct the same internal audit to verify that the negative audit findings have been fully corrected. Take the OIG's advice and use their work plan and their audit reports as a "heads-up" for coding and payment errors to audit internally.

REFERENCE