OIG Plans to Audit Dermatology E/M Claims

The April update to the OIG Work Plan has been released.  

The newest update includes dermatology claims for evaluation and management (E/M) services billed in addition to minor surgical procedures on the same date of service.  

The OIG indicated, in 2019, about 56% of dermatologists’ claims with an E/M service also included minor surgical procedures (such as lesion removals, destructions, and biopsies) on the same day. This may indicate abuse whereby the provider used modifier 25 to bill Medicare for a significant and separately identifiable E/M service when only a minor surgical procedure and related preoperative and postoperative services are supported by the beneficiary’s medical record. 

The documentation must support an E/M service is significantly and separately identifiable from procedural services in order to support the use of modifier 25.  In general, E/M services provided on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for a minor surgical procedure and must not be reported separately as an E/M service.

We recommend conducting internal auditing and monitoring of your E/M services billed in conjunction with minor dermatology procedures to verify compliance with the documentation and coding guidelines.

HBE’s team of coding and compliance experts is available to assist you external reviews of your documentation, coding and reimbursement as well as providing customized education and training for your staff.  We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.  

The OIG Work Plan is located at: https://oig.hhs.gov/reports-and-publications/workplan/index.asp

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel

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