HHS inspectors' action plan reveals hot buttons for fraud

E&M coding and billing for consultations top the list of physician activities to be scrutinized during 2004.

By Markian Hawryluk, AMNews staff. Oct. 20, 2003.

Washington -- Reminiscent of Claude Rains' immortal line from the movie "Casablanca," the Dept. of Health and Human Services' Office of Inspector General has decided to "round up the usual suspects."

In its work plan for 2004, the OIG said it would conduct investigations into many of the same problem areas it has identified in the past, including coding for evaluation and management services, billing for physician consultations and pricing for physician-purchased drugs.

Although the plan contains no bombshells, health care consultants and attorneys are treating the document as a guide to help physician practices avoid compliance issues. The action plan, they said, provides a clear indication of which issues anti-fraud investigations will spotlight.

"It really tells physicians what are going to be the major areas of focus for the OIG, what are the kinds of things they are going to be looking at during the next year," said Sherry Migliore, director of consulting for PMSCO Healthcare Consulting in Harrisburg, Pa.

The OIG said it planned to investigate physician coding of evaluation and management services, focusing on whether there were adequate controls to identify physicians with aberrant coding patterns.

Investigators also will look into the use of modifier 25, a code to indicate billing for E&M services on the same day as a procedure or other service. Generally, physicians cannot bill for both on the same day unless the E&M service is unrelated to the other procedure. In 2001, $1.7 billion of the $23 billion billed for E&M services was under modifier 25.