“Radiology services have unique characteristics, and some unique compliance considerations that accompany them include compliance rules associated with physician orders, medical necessity, local coverage determinations, and teaching physician settings.”
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“There’s another incredibly helpful resource that some might not be as familiar with: the list of services that Medicare Administrative Contractors (MACs) include in their Target, Probe and Educate (TPE) plan.”
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“There is no silver bullet to solving medical necessity risks as they relate to medical claims submitted to payers such as Medicare. That said, these tips can be a starting point for compliance programs who know they need to minimize their compliance risk around medical necessity.”
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“Code G2211, which can be added to specific E/M codes under certain circumstances, is now separately reimbursable by Medicare.”
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“Successful compliance programs are adapted to fit the organization and maximize compliance for individual organizations with unique risk profiles.”
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“Earlier this year, regulators made the most significant changes to E&M documentation and coding guidelines in over two decades. They’re more complex than ever before, and enforcement actions are increasing.”
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“Enforcement agencies like to “follow the money,” so to speak, and they often find it in medical claims submitted to government payors such as Medicare and Medicaid. This is why selecting appropriate modifier codes is essential for operating and being reimbursed compliantly.”
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“As healthcare fraud, waste, and abuse continues to emerge, and poses more of a risk to organizational compliance, professionals should become familiar with some of the potential areas of noncompliance associated with telehealth.”
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Christi Grimm, the Inspector General of HHS, gave a recent keynote address to compliance professionals. In it, she said, “Simply put, the financial incentives created by risk adjustment may be driving upcoding in the severity of diagnoses to garner additional payments.”
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