Updated on: June 22, 2021

HHS-OIG Getting Under the Skin of Dermatologists

By
Original story posted on: June 21, 2021

Readers are advised to monitor regularly the OIG Work Plan.

Even the most seasoned healthcare professionals and coders can get blindsided when they see a headline or a news alert and think, “wait, that can’t be correct…can it?”

Which is what happened to me as I monitored the U.S. Department of Health and Human Services-Office of Inspector General (HHS-OIG) workplan announcements daily, just to see what and who are the latest targets of oversight.

Late in April, I had a client come to me and say, have you seen the latest OIG alert for dermatologists? So I went to review my alerts, and sure enough, it was there:

April 2021

Centers for Medicare & Medicaid Services

Dermatologist Claims for Evaluation and Management Services on the Same Day as Minor Surgical Procedures

Office of Audit Services

W-00-21-35868

2021

This didn’t make sense to me, because as a rule, most dermatologists and general practice physicians see patients for skin lesions and removals on the same date as an evaluation and management (E&M) service. It’s not necessarily routine, as we know that it is hard to support medical necessity, but if a new patient comes in for an encounter for a complaint about a suspicious skin lesion, mark, or growth, the physician does a complete work-up, and in doing so, he or she finds a few additional lesions or skin tags that need removal, that service will be provided on the same date as the new patient office visit.

Also, patients that are known to the provider and have a history of skin cancer will be scheduled for periodic reassessments to monitor any new malignancies, and if found, may have them excised or a “destruction of tissue” procedure performed on the same date as the E&M established patient visit. The majority of these procedures are not “planned.” They are performed after the provider performs a medically necessary evaluation to determine the need for a minor procedure.

Well, after this alert came out, I went back to the General Correct Coding Policies for National Correct Coding Initiative’s (CCI’s) Policy Manual for Medicare Services, Chapter 1, pages 16-17, where it states:

“If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M service is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for Revision Date (Medicare): 1/1/2021 I-17 the procedure, and are not separately reportable. NCCI does not contain edits based on this rule because MACs have separate edits. If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. The NCCI program contains many, but not all, possible edits based on these principles.”

I had to read this at least three times to understand why Medicare would even have this policy, as it does not make sense to me. Think about this. In the underlined sections above, it says, “the decision to perform the minor procedure is included in the payment for the minor procedure and an E&M service cannot be performed separately.” How does this make sense if the physician could not make that decision prior to evaluating the patient? The relative value unit (RVU) for the minor surgical skin procedures are not inflated in payment to possibly include an E&M value, from what I can see.

If your provider performed a 17000, destruction of a premalignant lesion, on a patient after an exam found this lesion, this Centers for Medicare & Medicaid Services (CMS) rule says the physician is only entitled to $67.34, with a work RVU of 0.61. If your physician only billed for an office visit Level 3 E&M service, 99203, they would have received $113.75, with a work RVU of 1.60. However, this CCI direction states that this could not be billed at the same encounter if the E&M is for the decision on the minor procedure.

What is interesting is that there is a target on the backs of dermatologists and their services.

The OIG Work Plan states:

“Medicare covers an evaluation and management (E&M) service when the service is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Generally, Medicare payments for global surgery procedures include payments for necessary preoperative and postoperative services related to surgery when furnished by a surgeon. Medicare global surgery rules define the rules for reporting E&M services with minor surgery and other procedures covered by these rules. In general, E&M services provided on the same day of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for a minor surgical procedure and must not be reported separately as an E&M service. An E&M service should be billed only on the same day if a surgeon performs a significant and separately identifiable E&M service that is unrelated to the decision to perform a minor surgical procedure. In this instance, the provider should append a modifier 25 to the appropriate E&M code. In 2019, about 56 percent of dermatologists' claims with an E&M service also included minor surgical procedures (such as lesion removals, destructions, and biopsies) on the same day. This may indicate abuse whereby the provider used modifier 25 to bill Medicare for a significant and separately identifiable E&M service when only a minor surgical procedure and related preoperative and postoperative services are supported by the beneficiary's medical record. We will determine whether dermatologists' claims for E&M services on the same day of service as a minor surgical procedure complied with Medicare requirements.”

What makes me feel concern for dermatology practices is that the last sentence of the OIG alert is vague: “we will determine…” Are they medical professionals making that determination of medical necessity for the E&M service? What if other diagnoses were addressed during the E&M encounter, but the primary diagnosis submitted was for the skin procedure?

Taking this a step further, minor procedures, as described by the CCI policy manual, are 0-010-day global procedures. So, who’s next? Gastroenterologists giving colonoscopies on the same date as an E&M? General surgeons performing an incisional breast biopsy on the same date as an E&M? Or how about a radiologist who needs to have a counseling visit prior to a patient undergoing chemotherapy – again, is this related to the minor procedure?

I would encourage HHS-OIG to be more specific in their Work Plan items so that practices can be prepared – and I would encourage providers to make sure they are ready for any scrutiny that may come for medically necessary services they provided in good faith, if they wind up being questioned due to a policy that does not make a lot of sense.

Programming Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10 Eastern.

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS,  ACS-CA, SCP-CA, QMGC, QMCRC

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

Related Stories

  • A Warning from the OIG about Higher-Severity DRG Shift
    This OIG audit is an opportunity for us to be introspective. In February, a report came out from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) regarding their concern about an apparent increase in…
  • Explosive OIG Report Raises Red Flags for Providers, CDI Professionals 
    The report underscores federal authorities’ recent assertions that coding errors are generating ample unwarranted reimbursement. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) just released a data brief titled “Trend Toward More Expensive Inpatient…
  • It’s no Accident that the OIG is Going after Acute CVA
    Documentation of strokes is tricky. My personal provider’s MyChart has become pretty sophisticated. In preparation for an outpatient visit with my doctor, I have to review many aspects of my health history, including past medical history, medications, and allergies, and…