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Radiology Coding Alert

5 OIG Hot Spots and How to Steer Clear of Them

Want to avoid OIG scrutiny in 2004?  Watch your IDTF claims You've assigned the right code to an MRI, confirmed that the radiologist's interpretation is in the file, and clipped the ordering physician's MRI order to the patient's chart. Another pristine chart guaranteed to bring your IDTF quick payment, right? Not so fast. If a physician who is excluded from the Medicare program ordered the MRI in the first place, Medicare and other federal payers won't reimburse you for your work.
 
Although this has been the case for years under the U.S. Office of Inspector General (OIG) Exclusion Program, a recent OIG review has launched it into the spotlight and made it a major concern for radiologists. As an investigative focus area that the OIG identified in its recently released 2004 Work Plan, independent diagnostic testing facilities (IDTFs) and outpatient hospital departments will essentially have to "credential" every physician who orders Radiology services.
 
1. Did Excluded Physicians Order Radiology Testing? You Won't Get Paid. The Work Plan indicates that physicians excluded from federal healthcare programs are precluded from ordering and performing services for Medicare beneficiaries. A recent OIG review, however, revealed that excluded physicians ordered "a significant number of services."
 
Most IDTFs simply can't afford to have scores of diagnostic testing services denied just because an ordering physician was excluded from the Medicare program - and this is particularly frustrating when physicians don't self-disclose that they are excluded.
 
So how can you credential your facility's ordering physicians? The OIG maintains a database of excluded physicians. You can either download the entire database or search it using physician names or business names. Visit http://oig.hhs.gov/fraud/exclusions.html to access the database. Remember that this database is constantly changing, and you should make certain that you have current exclusion information. 2. IDTFs Must Buckle Down. The OIG will also investigate the medical necessity of services performed in IDTFs. On the docket is a review of whether such services were medically necessary, whether facilities had prior approval to provide such services, whether physicians appropriately supervised the services, and whether personnel who provided the services were properly credentialed. 3. Double-Check Orders for Diagnostic Tests in the ED. You need to be certain you have sufficient documentation before coding diagnostic tests your radiologist performs in the emergency department (ED).
 
The OIG intends to assess whether diagnostic tests performed in hospital emergency rooms are medically necessary and interpreted appropriately for the patient's condition. Because the Emergency Medical Treatment and Active Labor Act (EMTALA) requires that emergency room patients be screened and stabilized, radiologists are often called to test the patient as part of the "screening." If you perform diagnostic testing such as x-ray, ultrasound, angiography, myelography or other tests in [...]