An audit by the Office of Inspector General (OIG) revealed significant issues in Procedural Terminology Coding For Critical Care Services billed to Medicare. The audit, which examined claims from January 1, 2017, through March 31, 2019, highlighted a concerning improper payment error rate of 19.7 percent for critical care services nationwide, equating to approximately $198 million in 2018 alone. This prompted a focused review of Lahey Clinic, Inc., identified as a high-risk provider for noncompliance in Medicare billing for these essential services.
Key Findings of the OIG Audit at Lahey Clinic
The OIG’s audit of Lahey Clinic scrutinized 30,738 critical care services, amounting to $5.3 million in Medicare payments. A sample of 100 inpatient admissions, encompassing 1,410 critical care services, was meticulously examined. The findings indicated that while Lahey Clinic demonstrated compliance for 36 out of 92 reviewed services, a substantial 56 services were billed incorrectly. Alarmingly, every single inpatient admission reviewed contained at least one critical care service that failed to meet Medicare billing standards.
The discrepancies primarily fell into two categories:
- Lack of Medical Necessity: 54 services were billed as critical care when patient conditions did not warrant this level of care, or when physician-provided services did not align with the intensity required for critical care coding. This implies a potential over-coding of services, leading to inflated claims.
- Incorrect CPT Coding: Two services were billed using inappropriate Current Procedural Terminology (CPT) codes for the specific critical care services rendered. This points to errors in the application of procedural terminology coding guidelines.
These coding inaccuracies resulted in overpayments of $6,015 to Lahey Clinic. The OIG attributed these errors to deficiencies in Lahey’s internal policies and procedures. Specifically, the clinic lacked robust systems to ensure that physicians accurately documented and identified critical care services meeting Medicare criteria, and that coders correctly interpreted and applied procedural terminology coding for these services.
Impact of Coding Errors in Critical Care
The OIG audit at Lahey Clinic underscores the significant financial and compliance risks associated with inaccurate procedural terminology coding for critical care services. For providers, coding errors can lead to:
- Financial Penalties: Repayment of overpayments, fines, and potential exclusion from federal healthcare programs.
- Increased Scrutiny: Heightened audit risk and more intensive reviews from payers.
- Reputational Damage: Loss of public trust and potential harm to the provider’s reputation.
For the Medicare system, and ultimately taxpayers, incorrect coding inflates healthcare costs and depletes resources that could be allocated more effectively.
Recommendations for Accurate Procedural Coding
To mitigate these risks and ensure accurate procedural terminology coding for critical care services, healthcare providers should focus on strengthening the following areas:
- Enhanced Documentation Policies: Implement clear and comprehensive policies requiring physicians to thoroughly document the medical necessity and intensity of critical care services provided. Documentation should explicitly justify the use of critical care codes based on established guidelines.
- Coder Training and Education: Provide ongoing, specialized training for medical coders on the nuances of critical care coding, including CPT code selection, medical necessity criteria, and relevant Medicare guidelines. Regular updates on coding changes and best practices are crucial.
- Regular Audits and Reviews: Conduct internal audits of critical care coding and billing practices to identify potential vulnerabilities and areas for improvement. Proactive reviews can help catch errors before external audits occur.
- Clear Communication Between Clinicians and Coders: Foster effective communication channels between physicians and coding staff to clarify documentation ambiguities and ensure accurate code assignment.
Conclusion
The OIG audit of Lahey Clinic serves as a critical reminder of the importance of precise procedural terminology coding for critical care services. Accurate coding not only ensures compliance with Medicare regulations but also reflects the true level of care provided to critically ill patients. By prioritizing robust documentation, comprehensive coder training, and proactive internal reviews, healthcare providers can significantly reduce coding errors, mitigate financial risks, and maintain the integrity of Medicare billing practices for these vital services.
