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April 11, 2016

How to Avoid Running Afoul of the DHS OIG

April 11, 2016

anesthesia billing and coding

Every year, the Office of the Inspector General for the Department of Health and Human Services releases a Work Plan that covers the office's plan to oversee, audit, and ensure compliance with all programs and guidelines under the DHS aegis.

The Work Plan is a starting point for any provider that is paid under the Centers for Medicare and Medicaid Services (CMS). This is because the OIG is tasked with overseeing CMS operations and pursuing action against anyone found to be fraudulently or unintentionally violating regulations. This includes improper reporting and over-billing.

In this year's Work Plan, the OIG was careful to specify one particular action that anesthesia providers often take that can cause a provider to run afoul of regulations – and potentially face punishment.

Using the Correct Service Code Modifier

One practice the OIG wants to squash is intentionally or unintentionally using the wrong service code modifier when filing a claim under Medicare Part B for anesthesia service provided to a patient.

For example, care that is personally administered by an anesthesiologist should use the “AA” modifier. The “QK” modifier is for medically-directed anesthesia; “QX” is for CRNA service with medical direction by a physician; “QY” is for medical direction for a CRNA by an anesthesiologist; “QZ” is for CRNA service without medical direction; and “GC” is for residents who are under the direction of a teaching physician.

This is important to know because incorrectly recording a modifier – say, using “AA” instead of “QK” – will result in a higher (incorrect) payment from Medicare. Doing so intentionally is fraudulent. The “QK” modifier in this instance would limit payment to 50% of the amount allowed by Medicare for any services claimed with the “AA” modifier.

With rising instances of audits, it's important to properly record each procedure, which is why the Work Plan specifies this in the 2016 version.

Reviewing Medicare Part B Claims

Under the Work Plan 2016, the OIG will review claims under Medicare Part B to ensure that all anesthesia claims are supported in accordance with requirements under the Medicare program. This specifically means that all records will be reviewed to make sure that a patient who received anesthesia care also received care from a related Medicare service. Medicare will not pay for any service that is not “reasonable and necessary.”

It's important to review all of your claims before they are submitted to make sure they do not run afoul of the OIG and all Medicare-related regulations. An anesthesia billing and coding provider can help you make sure you are in full compliance and avoid an audit.

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