The government is keeping a close eye on how you are coding claims. Are you?

The Office of Inspector General (OIG) is updating its Work Plan this month with new watch items that pertain to Medicare. At press time, there were five additional items the OIG intends to pursue in 2020.

OIG Work Plan items added in October:

• Review of Hospice Inpatient and Aggregate Cap Calculations
• Medicare Part B Payments for Speech-Language Pathology
• Review of Medicare Payments for Power Mobility Device Repairs
• Review of Medicare Part B Urine Drug Testing Services
• Supplier Compliance with Medicare Requirements for Replacement of Positive Airway Pressure Device Supplies

If your organization bills for any of these services, now would be a good time to perform internal audits on applicable claims.

Review of Hospice Inpatient and Aggregate Cap Calculations

The OIG will be looking for overpayments made to hospices that exceeded the inpatient and aggregate caps and failed to repay the government.

Federal Guidelines

The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20 percent of a hospice’s total Medicare patient care days. A hospice must refund to Medicare any payment amounts in excess of the inpatient cap. The aggregate cap limits the total aggregate payments that any individual hospice can receive in a cap year to an allowable amount based on an annual per-beneficiary cap amount and the number of beneficiaries served. Any amount paid to a hospice for its claims in excess of the aggregate cap is considered an overpayment and must be repaid to Medicare. Hospices must file their self-determined aggregate cap determination notice with their Medicare Administrative Contractor (MAC) within 5 months after the end of the cap year and remit any overpayment due at that time.

Medicare Part B Payments for Speech-Language Pathology

The OIG will be looking at claims for proper modifier KX use and evaluating payment trends to detect outliers.

Federal Guidelines

When Medicare payments for a beneficiary’s combined physical therapy and speech therapy exceed an annual therapy spending threshold, the provider must append modifier KX to the appropriate procedure code reported on the claim.

For calendar year 2019, the modifier KX threshold amount is:

• $2,040 for physical therapy and speech-language pathology services combined, and
• $2,040 for occupational therapy services.

Review of Medicare Payments for Power Mobility Device Repairs

The OIG will audit Medicare payments for power mobility device (PMD) repairs to determine whether durable medical equipment (DME) suppliers complied with Medicare requirements.

Federal Guidelines

DME suppliers must:

• Maintain documentation from the physician or treating practitioner indicating that the PMD being repaired continued to be medically necessary and that the repairs were reasonable and necessary.
• Maintain detailed records describing the need for and nature of all repairs, which includes a justification for the replaced parts and the labor time.

If the expense for repairs exceeds the estimated expense of purchasing or renting another PMD for the remaining period of medical need, no payment can be made for the excess.

Review of Medicare Part B Urine Drug Testing Services

The OIG says they will review urine drug testing (UDT) claims for Medicare patients with diagnoses related to substance use disorders (SUDs).

Federal Guidelines

Current coding for testing of drug abuse relies on a structure of “screening” (known as “presumptive” testing) and “quantitative” or “definitive” testing that identifies the specific drug and quantity in the patient. Beginning Jan. 1, 2017, presumptive drug testing may be reported with CPT® codes 80305-80307. These codes differ based on the level of complexity of the testing methodology. Only one code from this code range may be reported per date of service. See MLN Matters® article SE18001 for details.

Supplier Compliance with Medicare Requirements for Replacement of Positive Airway Pressure Device Supplies

The OIG will review Medicare claims for frequently replaced positive airway pressure (PAP) device supplies (e.g., mask, tubing, headgear, and filters) at selected suppliers to determine whether documentation requirements for medical necessity, frequency of replacement, and other Medicare requirements are met.

Federal Guidelines

For supplies and accessories used periodically, orders must specify the type of supplies needed, the frequency of use, if applicable, and the quantity to be dispensed; and suppliers must not automatically ship refills on a predetermined basis (Centers for Medicare & Medicaid Services Medicare Program Integrity Manual, Pub. 100-08, Ch. 5, §§ 5.2.3 and 5.2.8).

The OIG provides independent oversight of federal programs and operations of the U.S. Department of Health and Human Services (HHS). The OIG Work Plan, which lists planned oversight projects, is adjusted monthly throughout the year.