HHS-OIG Getting Under the Skin of Dermatologists

Readers are advised to monitor regularly the OIG Work Plan.

Even the most seasoned healthcare professionals and coders can get blindsided when they see a headline or a news alert and think, “wait, that can’t be correct…can it?”

Which is what happened to me as I monitored the U.S. Department of Health and Human Services-Office of Inspector General (HHS-OIG) workplan announcements daily, just to see what and who are the latest targets of oversight.

Late in April, I had a client come to me and say, have you seen the latest OIG alert for dermatologists? So I went to review my alerts, and sure enough, it was there:

This didn’t make sense to me, because as a rule, most dermatologists and general practice physicians see patients for skin lesions and removals on the same date as an evaluation and management (E&M) service. It’s not necessarily routine, as we know that it is hard to support medical necessity, but if a new patient comes in for an encounter for a complaint about a suspicious skin lesion, mark, or growth, the physician does a complete work-up, and in doing so, he or she finds a few additional lesions or skin tags that need removal, that service will be provided on the same date as the new patient office visit.

Also, patients that are known to the provider and have a history of skin cancer will be scheduled for periodic reassessments to monitor any new malignancies, and if found, may have them excised or a “destruction of tissue” procedure performed on the same date as the E&M established patient visit. The majority of these procedures are not “planned.” They are performed after the provider performs a medically necessary evaluation to determine the need for a minor procedure.

Well, after this alert came out, I went back to the General Correct Coding Policies for National Correct Coding Initiative’s (CCI’s) Policy Manual for Medicare Services, Chapter 1, pages 16-17, where it states:

I had to read this at least three times to understand why Medicare would even have this policy, as it does not make sense to me. Think about this. In the underlined sections above, it says, “the decision to perform the minor procedure is included in the payment for the minor procedure and an E&M service cannot be performed separately.” How does this make sense if the physician could not make that decision prior to evaluating the patient? The relative value unit (RVU) for the minor surgical skin procedures are not inflated in payment to possibly include an E&M value, from what I can see.

If your provider performed a 17000, destruction of a premalignant lesion, on a patient after an exam found this lesion, this Centers for Medicare & Medicaid Services (CMS) rule says the physician is only entitled to $67.34, with a work RVU of 0.61. If your physician only billed for an office visit Level 3 E&M service, 99203, they would have received $113.75, with a work RVU of 1.60. However, this CCI direction states that this could not be billed at the same encounter if the E&M is for the decision on the minor procedure.

What is interesting is that there is a target on the backs of dermatologists and their services.

The OIG Work Plan states:

What makes me feel concern for dermatology practices is that the last sentence of the OIG alert is vague: “we will determine…” Are they medical professionals making that determination of medical necessity for the E&M service? What if other diagnoses were addressed during the E&M encounter, but the primary diagnosis submitted was for the skin procedure?

Taking this a step further, minor procedures, as described by the CCI policy manual, are 0-010-day global procedures. So, who’s next? Gastroenterologists giving colonoscopies on the same date as an E&M? General surgeons performing an incisional breast biopsy on the same date as an E&M? Or how about a radiologist who needs to have a counseling visit prior to a patient undergoing chemotherapy – again, is this related to the minor procedure?

I would encourage HHS-OIG to be more specific in their Work Plan items so that practices can be prepared – and I would encourage providers to make sure they are ready for any scrutiny that may come for medically necessary services they provided in good faith, if they wind up being questioned due to a policy that does not make a lot of sense.

Programming Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10 Eastern.