OIG Audit Shows 40 Percent of Providers Non-compliant in Billing

F.J. Thomas

Sarasota, FL (WorkersCompensation.com) – Optimal documentation or coding for physicians isn’t a strong focus while in residency. As physicians are ultimately held responsible for coding the claims that they bill, it’s no secret in healthcare that even with all the coding tools available, there is still a high rate of errors on claims, especially with medical policies that change on an almost daily basis and difficult electronic health record software. According to the American Academy of Professional Coders (AAPC), in 2019 some of the top claim errors were the result of not meeting medical necessity and insufficient documentation, especially for orthopedic and spine. While CMS estimates an error rate of 7.25 percent in 2019, and 6.27 in 2020, other estimates of billing errors are as high as 80 percent.

In a release earlier this month, the Department Of Health and Human Services, Office of Inspector General (OIG) announced that Medicare overpaid $636 million for neurostimulator surgeries that were found to be improperly billed due to insufficient documentation. CMS audited claims from 2016 to 2017 that contained procedure codes 61885, 61886, or 63685, covering $1.4 billion in payments, and 58,213 beneficiaries.

Neurostimulators were initially approved by the Food And Drug Administration for the treatment of chronic pain, but were quickly found to be beneficial for other conditions such as Parkinson’s, epilepsy, and a wide range of tremor and seizure conditions, for which Medicare issued National Coverage Determinations (NCDs) in 1995. Part of the requirements listed in the NCDs is that the device be used as a last resort, that all other treatment modalities have failed, and a demonstration of pain relief with the use of a temporary implanted electrode prior to surgery. Additionally, a multidisciplinary screening including a psychiatric evaluation is required.

The auditors reviewed a stratified random sample of 124 claims totaling $3.4 million. The claims were billed by 102 providers, and included a total of 106 beneficiaries. The auditors found that more than 40 percent of the providers were not compliant in billing for the neurostimulator implantation surgeries.

The documentation in the medical records from 46 of the medical providers did not support the surgeries billed, with the bulk of them not meeting the NCDs requirements for chronic pain. The records for 7 beneficiaries were missing documentation that other treatments had not been successful. A total of 34 records did not indicate the required multidisciplinary screening including a psychological evaluation had been done. A total of 8 records were missing documentation indicating a temporary implant had been done previously. Additionally, some of the providers stated that they did not fully understand Medicare’s coverage requirement.

As a result of the audit, CMS issued a final rule that requires prior authorizations for implanted spinal neurostimulators effective July 1, 2021. The final rule does not apply to cases where the neurostimulator is implanted for Parkinson’s or seizure disorders.

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