OIG

In 2002, an OIG report found that Medicare inappropriately reimbursed podiatrists for Routine Foot Care Services that were found to be medically unnecessary and insufficiently documented. Since the OIG had not reviewed podiatry services since that report back in 2002, an audit was conducted to determine whether these compliance issues continued to exist during the subsequent audit period, 2019 and 2020. The audit examined whether podiatrists’ claims for Routine Foot Care Services related to a covered systemic condition complied with Medicare’s requirements. Of the 100 claims that were sampled, 49 claims for Routine Foot Care Services related to a covered systemic condition did not comply with Medicare requirements. As a result of the audit, the OIG opined that CMS’s oversight may not have been sufficient to prevent improper payments. The OIG estimated that of the $18.2 million paid by Medicare during the audit period, approximately $4.4 million did not comply with Medicare’s requirements.

In 2019, the OIG performed an audit of claims that were billed by podiatrists for E/M services. The audit examined whether podiatrists’ claims for E/M services billed with the 25 modifier, which indicates that the E/M service was significant and separately identifiable from a minor surgical procedure billed on the same date of service, one that has a postoperative global period of 0 or 10 days, complied with Medicare’s guidelines. One hundred (100) claims were sampled, and it was found that forty-four (44) claims did not comply with Medicare’s guidelines. The OIG estimated that $39.6 million of the $222.5 million paid by Medicare during the audit period was inappropriate. It was found that during the audit period, CMS’s oversight may not have been sufficient to prevent improper payments.

Consider an internal audit referred to as a compliance audit of your chart notes/medical record documentation and billing/coding to determine if you are potentially at risk of an audit or clawback by CMS, the Centers for Medicare and Medicaid Services or by a commercial health insurance carrier and determine what steps need to be taken to mitigate those risks. It is inevitable that in all likelihood a provider will be audited. An audit should never be more than an inconvenience. It should not be a life-changing event. If a clawback takes place, it would be bad enough if face value reimbursements were requested after the fact. Unfortunately, this is usually not what occurs. The assumption is that since the billing, coding and documentation did not support the claim(s) that were filed, the requested amount to be repaid will be far greater. Interest, penalties and an extrapolation is instituted referred to as the Statistically Valid Random Sample or SVRS that will result in an amount that needs to be repaid that is far greater than what was initially reimbursed.

What is the Difference Between a Simple Repair of a Wound, an Intermediate Repair of a Wound and a Complex Repair of a Wound?