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OIG Report Highlights Need to Understand Guidelines

Wyn Staheli, Director of Research
2020-07-28

A July 2020 OIG report once again highlights the necessity for organizations to fully understand requirements for codes. A review of the report shows that providers failed to meet Medicare requirements. Even though this particular review was for psychotherapy services, these types of problems are ongoing issues for multiple types of services and specialties and for many different payers as well:

  • Treatment plans did not comply with Medicare requirements
  • Therapeutic maneuvers were not specified in beneficiaries’ treatment notes
  • Treatment notes did not support services billed
  • Treatment plans did not document if a beneficiary’s condition improved or had a reasonable expectation of improvement
  • Treatment notes were “signed” with digital images of clinicians’ signature
  • Treatment time was not properly documented

The following are some key takeaways from the report that all healthcare providers and organizations need to pay attention to:

  • Medical necessity: Be sure to carefully review payer policies regarding their requirements. Most include requirements that the treatment must have an expectation of improvement or that the service is only covered under certain conditions (e.g., specific diagnoses). Do NOT change a diagnosis to ‘fit’ their requirements but be sure to understand in what situations a service will be covered. Take time to educate the patient on what will be covered and use a notice of noncoverage particularly when required by the payer.
  • Time: When code descriptions specify a time, it is essential to meet the basic requirements for that code. If the code description says 15 minutes, a minimum of 8 minutes (unless otherwise specified in the code guidelines) must be met in order to report that service. Some payers want to see both start and stop times so it is essential to understand each payer policy. See one of Find-A-Code’s specialty-specific Reimbursement Guides for more comprehensive information.
  • Signatures: Most payers have policies about signature requirements and Medicare is no exception. You cannot use an image. Signatures may be handwritten, or electronically signed. Documentation must be signed appropriately by the healthcare provider in accordance with the payer’s policy.
  • Progress Reports: Payers want to see indications of improvement. Vague statements like “patient feels better” are not as concrete as something more precise like “patient reports 50% improvement in pain.”

These are all areas that should be addressed as part of any documentation improvement plan to ensure compliance.

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