The OIG has released two new reports detailing high payment error rates for Advanced Care Planning and Assistant at Surgery and Co-Surgeon Services.
ACP services have previously been identified as having high billing error rates. The most recent OIG audit estimates Medicare paid $42.3 million for ACP services that did not comply with Federal requirements. The types of errors identified by the OIG included:
- The documentation did not support the distinct time spent performing ACP services..
- The documentation did not support an ACP discussion occurred.
- The documentation did not support the medical necessity for multiple, repeat ACP discussions.
- ACP services must be provided by a physician or other qualified health care professional.
- Requires counseling and discussion of advance directives with patient, family member or surrogate decision maker.
- ACP services of less than 16 minutes should not be billed.
- Do not count time spent performing non-ACP services towards the ACP time.
- Documentation should include:
- A summary of the discussion including the voluntary nature of the service.
- Documentation indicating the explanation of advance directives.
- Who was present.
- The time spent in ACP discussion.
- Rationale/necessity for repeat ACP discussions (i.e. change in patient’s health status, end-of-life wishes, or both).
Co-surgeries and Assistant-at-Surgeries
The OIG also issued an audit report that found Medicare made $4.9 million in improper payments for professional surgical services. The types of errors identified by the OIG included:
- Failure to properly report co-surgeon services with modifier 62
- Failure to properly report assistant surgeon services with modifier 80, 81, 82 or AS
Co-Surgery and Assistant-at-Surgery Reminders
- Co-surgeries are performed by two surgeons, both working as a primary surgeon, completing distinct parts of the procedure.
- Both surgeons should document an operative report outlining their portion of the operation.
- Both surgeons should report their service with same CPT code(s) and modifier 62 (Co-Surgery).
- An assistant-at-surgery is a physician who actively assists the physician performing the surgery.
- Assistant-at-surgery services must be more than ancillary services.
- The operative report should clearly detail the necessity of the assistant and the specific services performed by the assistant.
- The assistant should report the appropriate CPT code(s) with one of the following modifiers as appropriate:
- MD/DO assistant-at-surgery, modifier 80
- Minimal assistant service, modifier 81
- MD/DO assistant-at-surgery due to unavailability of resident, modifier 82
- NP/PA assistant-at-surgery, modifier AS
We recommend auditing and monitoring of these services as applicable to your organization to validate compliance with the documentation and billing requirements outlined by CMS. The specific data analysis and auditing techniques detailed within the OIG reports are a valuable roadmap for providers.
HBE’s team of experts is available to assist you with risk assessments, routine auditing and monitoring, policy and procedure development as well as customized education and training for your clinical and administrative staff.
The OIG ACP Report is located here: https://oig.hhs.gov/oas/reports/region6/62004008.asp
The OIG Co-surgery Report is here: https://oig.hhs.gov/oas/reports/region1/12000503.asp
The CMS FAQs for ACP: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/faq-advance-care-planning.pdf
The CMS Medlearn Booklet is here: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf
The Medicare Claims Processing Manual, ch. 12, sections 20.4.3 (Assistant-at-Surgeries) and 40.8 (Co-surgeons) is here: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf