Hospital Outpatient E&M under OIG Focus

The OIG determination that E&M coding, especially the determination of new patient vs. established patient criteria will become an increasingly important area for physician practices, especially inside institutions that are switching EMR and billing records. Many of these conversions have led to erroneous classification.

The OIG Work Plan for Part A states a review of Medicare outpatient payments made to hospitals for evaluation and management (E/M) will be conducted in 2015. The focus is specific to E/M services for clinic visits billed at the new-patient rate to determine whether those claims were appropriate and will recommend recovery of overpayments.

Preliminary OIG work identified overpayments occurred because hospitals used new-patient codes when billing for services to established patients. The rate at which Medicare pays for E/M services requires hospitals to identify patients as either new or established, depending on previous encounters with the hospital.

According to Federal regulations, the meaning of “new” and “established” pertains to whether the patient has been seen as a registered inpatient or outpatient of the hospital within the past 3 years. (73 Fed. Reg. 68679 (November 18, 2008).) (OAS; W-00-14-35627; expected issue date: FY 2015).

OIG and Quality of Care
The OIG 2015 planned work will examine settings in which OIG has identified gaps in program safeguards intended to ensure medical necessity, patient safety, and quality of care. The government continues to strive to pay for quality and access of health care services.

Clinical Documentation Improvement
Appropriate payment of claims starts with documentation to support accurate code assignment. Improve the documentation standards at your inpatient or outpatient facility through professional Clinical Documentation Improvement (CDI) training.Clinical documentation (for both inpatient and outpatient records) is more than recording accurateand timely information for coordination of patient care. Clinical Quality Measures (CQM), Physician Quality Reporting Systems (PQRS), reimbursement and ICD10systems, Required EHR and meeting meaningful use criteria drive the need for improved clinical documentation. This affects clearing houses, payers, all provider-types (clinics, hospitals, nursing homes, home health agencies, DME companies) creating an impact across the health care industry.

Consider training to educate and credential as a CDI professional. Here is what you will learn:

Basics of Clinical Documentation Improvement

• Role of CDI Programs & Professionals
• Authentication Rules for Records
• Amendments, Corrections and Delayed Entries
• Recordkeeping Principles

• OIG Compliance
• Increasing Public Awareness and Concern

• Chief Complaint, HPI, ROS, PFSH, Present on Admission (POA) Guidelines

• 1995 Documentation Guidelines
• 1997 Documentation Guidelines
• Hospital-Acquired Conditions (HACs)

• Data to Prevent Future Harm to Patients
• Hospital Readmissions Reduction Program
• Hospital Quality

• Comparing ICD-9-CM to ICD-10-CM
• Inpatient Procedures – Root Operations
• Span Dates

• Certain Infectious and Parasitic Diseases
• Neoplasms
• Endocrine
• Nutritional & Metabolic Diseases
• Mental & Behavioral Disorders
• Nervous System
• Sense Organs: Eye & Adnexa; Ear & Mastoid
• Integumentary System
• Musculoskeletal System
• Genitourinary System
• Pregnancy, Childbirth & Puerperium
• Perinatal Congenital Conditions
• Signs, Symptoms & Abnormal Findings
• Injury, Poisoning & External Causes
• 7th Character Chart for Reporting Fractures Classification
• Index Poisoning
• Under Dosing Maltreatment
• Complications of Care
• External Causes of Morbidity Factors Influencing Health Status

Source: American Institute of Healthcare, Compliance Update