Federal auditors at the HHS Office of Inspector General (OIG) have been busy: Earlier this year they released a scathing report on non-compliant instances of hyperbaric oxygen chamber (HBO) therapy in Wisconsin, and now they’ve updated the existing 2018 OIG Work Plan with a bevy of new targets, including physician billing of critical care codes.
First, wound care and HBO therapy. Wound care in general and HBO treatments in particular have long been a hobby horse for the OIG, thanks to chronic physician misunderstanding on Medicare’s admittedly lengthy and restrictive guidelines for services such as excisional debridements and HBO therapy.
They are a heavy drain on Medicare’s resources, and a February 2018 OIG report found an astonishing 85% error rate on a sample of 120 outpatient claims for HBO therapy submitted to WPS Government Health Administrators, the Medicare contractor covering Part B jurisdictions J5 (Iowa, Kansas, Montana, and Nebraska) and J8 (Indiana and Michigan).
The report reviewed WPS claims from 2013 to 2014, when J5 included the state of Wisconsin (it no longer does and NGS is now contractor for Wisconsin). It found that 102 out of 120 HBO services were not compliant with the requirements specified in Medicare’s national coverage determination. The findings showed overpayments of $300,789 out of $438,210 billed, and the OIG gave WPS recommendations to recover that money ASAP.
If you have a client that performs HBO therapy, you understand that the HBO chamber is a costly piece of equipment and that a wide range of clinical conditions could stand to benefit from HBO “dives.” The problem is CMS and most commercial payers still see the HBO chamber as mostly unproven technology, with uneven clinical outcomes. So they have a restrictive list of covered diagnoses, and a set of rules that go beyond that. Here’s some tips on how to avoid the biggest compliance mistakes the OIG uncovered:
- Billing for HBO to treat non-covered diagnoses. This should be a non-starter; the CMS coverage determination has a list of 15 covered diagnoses and anything not on the list won’t be a compliant use of HBO.
- Not stating that 30 days of standard therapy was attempted before initiating HBO therapy. Because HBO is covered as an adjunct or second-line treatment, it only becomes covered if conventional or first-line treatment has failed. So the physician initiating HBO must document this fact. A list of attempted treatments isn’t going to cut it – don’t make federal auditors guess, make your physicians state unequivocally that HBO is being initiated because standard care isn’t working.
- Not assessing the wounds every 30 days to justify ongoing HBO. Once started, HBO is covered for up to 30 days before the physician must reassess the wounds and determine if HBO is helping. Then and only then will another 30 days be supported.
- Not documenting (or performing) concurrent conventional therapy during HBO. CMS holds that HBO cannot be the sole treatment, and that conventional methods must also be in use for certain covered conditions, such as soft tissue radionecrosis.
The OIG has also long scrutinized excisional debridement procedures, as surgeons and podiatrists have a tendency to keep billing for the more expensive excisional codes even when they are actually performing maintenance debridement (billed using lower-cost selective debridement codes). The Wisconsin report on HBO therapy shows the OIG is opportunistic in launching small-scale localized investigations on targets that it has previously listed in its Work Plan to review on a national level.
New OIG Work Plan targets
Of these, probably the most important for physicians is the item targeting critical care services. Billed using two time-based CPT codes (99291 and 99292), these are E/M services that require documentation explicitly describing the work done by a physician to prevent a life-threatening deterioration in a patient’s condition.
The documentation should also of course show that the patient qualifies as “critically ill.” A patient being in an intensive care unit does not automatically qualify as critically ill without proper documentation. In addition to reviewing this requirement, the OIG will be scrutinizing the documentation of time spent with the patient. “Medicare pays physicians based on the number of minutes they spend with critical care patients,” the OIG says in its Work Plan update. “The physician must spend this time evaluating, providing care and managing the patient’s care and must be immediately available to the patient. This review will determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.”