Compliance Red Flag: Bring up to date your modifier 59 & Incident To Guidelines

You should keep signature, modifier 59, and ‘incident to' guidelines front and center, CMS has offered answers on when you are in the clear and …

You should keep signature, modifier 59, and ‘incident to’ guidelines front and center.

If you have been perturbed because of the fact that the oncologist’s illegible signature on an order is going to come back to trouble your practice in an audit, CMS has offered answers on when you are in the clear and when that untidy scrawl could have reviewers asking for more information.

1. Get signature guidelines down pat

With some exceptions, Medicare needs a signature for services and orders. The agency updated the rules and added e-prescribing language to the mix in Transmittal 327, CR6698. The rules instruct contractors reviewing claims on what counts as a signature and when the services or orders must have signatures.

One key exception to the signature requirement is that “diagnostic orders needn’t be signed by the physician,” according to Kelly Loya, CPC-I, CPhT, consultant with California-based Sinaiko Healthcare Consulting Inc. However, the medical record must still include information verifying the ordering physician intended the test to be carried out, and “a progress note in the medical record must be signed,” explains Loya.

A very useful feature of the transmittal is a chart that “gives specific facts as to what meets the requirements or requires follow up with the provider to meet the requirements or needs follow up with the provider to meet the requirements,” Loya says. For instance, if you can scan the chart, you can quickly see that an illegible signature written above a typed name is OK, however contractors won’t count just an unsigned typed note with a typed name. “The reviewer can look at alternative methods in order to verify the signature requirement,” notes Loya. She warns that not complying with an attestation request (within 20 days of the request) could lead to a denial.

If you have been reporting G8533 (at least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX system), see to it that you give the transmittal a close look. The new e-prescribing language solidifies that for non-controlled substances as long as a ‘qualified’ e-prescribing system (per Medicare Part D requirements) is used, a pen and ink copy” of the signed prescription order is not needed, according to Loya. However physicians cannot e-prescribe controlled substances – for instance, addictive pain medications – so CMS needs a pen and ink order for these.

Look out for change: Recently, the Drug Enforcement Agency released its interim final rule on e-prescribing controlled substances. If your oncologist is willing to jump through the multi-step authentication hoops, e-prescribing controlled substances may be likely in the future.

Transmittal 327 is effective March 1.

2. OIG is keeping a close look at Modifier 59; are you?

The OIG released its 202-page Compendium of Unimplemented OIG Recommendations,” which showed that many OIG suggestions have been ignored.

Here’s a case in point: In the year 2003, the OIG detected a 40 percent error rate on claims that contained modifier 59 (District procedural service) when used to separate correct coding edits, resulting in Medicare paying $59 million in improper payments.

The OIG urged carriers to institute prepayment and postpayment reviews of the use of modifier 59, and suggested that CMS should update carriers’ claims processing systems so they pay claims with modifier 59 “only when the modifier is billed with the correct code,” the OIG report indicates. According to the OIG, the CMS has not yet instituted such system edits, and notes that it’ll continue to monitor CMS’s endeavors to implement edits to make sure correct coding.”

What does this mean: “The OIG lists modifier 59 as a priority nearly every year, and it is possible that the agency feels that CMS should be looking more closely at its use,” Randall Karpf with East Billing in East Hartford, Conn says. “The bottom line is that if all of these entities are watching modifier 59, see to it that you are using it properly.”

Particularly, past OIG investigations have shown that one of the more common modifier 59 goof ups is incorrectly unbundling (Bone marrow; aspiration only) and 38221 (… biopsy, needle, or trocar); as such you should keep a careful watch on this code pair.

To add to it: The OIG examined services billed using the “incident to” guidelines, which you should be well-versed with if your report oncology services to Medicare. As a consequence of the OIG scrutiny , the agency is revising its incident to polices to reflect the fact that “no one except licensed physicians carry out the services or nonphysicians who have the required training, certification, and/or licensure, pursuant to state laws, state regulations, and Medicare regulations carry out the services under the direct supervision of a licensed physician.”

Although many practices already follow this rule, the OIG “wants an explicit rule rather than the present implicit rule,” according to Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.