Office of Inspector General (OIG) Identifies Two Key Work Plan Topics for 2018

Medical Billing

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Each month, the Office of Inspector General (OIG) publishes various Work Plans (topics) that target concerns raised by Congress, the Centers for Medicare and Medicaid Services (CMS) and other organizations, on which the OIG will focus for the current fiscal year or beyond. 

Following are two recent targets posted for the fiscal year 2018.

Review of Medicare Payments for Bariatric Surgeries

Bariatric surgery is performed to treat comorbid conditions associated with morbid obesity. (A comorbid condition exists simultaneously with another medical condition.) Medicare Parts A and B cover certain bariatric procedures if the beneficiary has (1) a body mass index of 35 or higher, (2) at least one comorbidity related to obesity, and (3) been previously unsuccessful with medical treatment for obesity (CMS, Medicare National Coverage Determinations Manual, Pub. No. 100-03, chapter 1, part 2, § 100.1). Treatments for obesity alone are not covered.

The Comprehensive Error Rate Testing program’s special study of certain Healthcare Common Procedure Coding System codes for bariatric surgical procedures found that approximately 98 percent of improper payments lacked sufficient documentation to support the procedures (CMS, Medicare Quarterly Provider Compliance Newsletter, “Guidance to Address Billing Errors,” volume 4, issue 4, July 2014). The OIG will review supporting documentation to determine whether the bariatric services performed met the conditions for coverage and were supported in accordance with federal requirements [Social Security Act, §§ 1815(a) and 1833(e)].

Independent Physical Therapists’ High Use of Outpatient Physical Therapy Services


Previous OIG work found that claims for therapy services provided by independent physical therapists were not reasonable and were not properly documented, or the therapy services were not medically necessary. Medicare will not pay for items or services that are not “reasonable and necessary” [Social Security Ace § 1862(a)(1)(A)].

The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they complied with Medicare reimbursement regulations. The OIG’s focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Documentation requirements for therapy services can be found in Centers for Medicare and Medicaid Service’s Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 220.3

Learn more about the OIG Work Plans.

Please contact Yeo & Yeo Medical Billing & Consulting with questions regarding these topics.


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