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OIG Inspection Report Shows $45 Million in Overpayments

The OIG released an inspection report on transforaminal epidural injections shows $45 million in overpayments in 2007.  Data shows that there was almost a 150% increase comparing Part B physician payments for transforaminal epidural injections in 2003 ($57 mil) and 2007 ($141 mil.)

Here are the report's key findings:

1.  34% of transforaminal epidural injection services allowed by MCR in 2007 did not meet MCR requirements ($45 mil. in overpayments):

• 19% of these services had a documentation error (which were more likely to occur in an office setting)
• 13% had a medical necessity error
• 8% had a coding error; and
• 7% had an overlapping error

2.  In 2007 the majority (9 of 14) of contractors had an LCD for the services but only one enforced all LCD requirements with an edit.

CMS's recommendations include provider education and the strengthening of safeguards.  We at ACE recommend that you perform an internal audit in response to this report. 

You can read the full OIG Report here. 

What's in a Form?

Every practice has forms to document the services provided but few forms are comprehensive and easy to use.  A well designed form will aid the provider in documenting all elements to be considered at each stage of care in a logical and concise manner.  The most common forms used by anesthesia practices are the Pre-Evaluation, Anesthesia Record, and Post-Operative Evaluation forms.  Many anesthesia practices have developed additional forms specifically for invasive line placement, pain block placement, and obstetrics.   This is not a contest to see how many forms can be used by a practice, but rather the recognition of specific information regarding the patient care that needed to be documented.  Although there are additional requirements for hospital based services to meet the Hospital Conditions of Participation for Medicare, standardizing forms across all facilities can benefit the practice by having consistent documentation of services across locations for providers. 
All forms should clearly identify the purpose of the form, facility, and patient identification.  Each form should have a form number and a revision number or last reviewed date.   This is where the similarity ends.  Let’s examine the specific key elements that should be included in the form for each stage of care.
A comprehensive pre-evaluation form should include:

• Procedure and Admission Information
• Medical History
• Anesthesia History
• Medication/Allergy History
• NPO Status
• Complete Physical Exam  - specific documentation for Heart, Lungs, Airway, Dental, and Vital Signs
• Review of Diagnostic Data and Medical Records
• ASA Physical Status
• Anesthesia Plan
• Indication for Premedication and Antibiotic Administration
• Acknowledgement that the risks, benefits, and alternatives have been explained and all patient questions have been answered
• Note area for any consultation or additional information
• Provider Signature, Date, and Time – there should be multiple areas if your practice includes CRNAs, AAs, and/or Residents

A comprehensive anesthesia record should include:

• Immediate ID Area
• Equipment, Drugs, and Supplies Checked
• Procedure Area
• Diagnosis Area
• Providers
• Anesthesia Start and End Times
• Type of Anesthesia with adequate documentation for the procedure, drugs, and fluids
• Monitoring of Vitals, O2, and Vent
• Invasive Line Documentation including line type, site, needle size, MSBT (cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis), utilization/medical necessity, notes/complications, provider, and start and end times
• Pain Block Documentation including catheter type, entry site, drug and amount, notes/complications, provider, date,  and start and end times
• Medical Direction for Induction, Monitoring, and Emergence, if your practice intends to medically direct CRNAs
• Antibiotic Documentation including time given
• Transfer of Care Documentation including Time and Signature
• Teaching Attestation Area if your practice includes Residents or SRNAs
• Problems/Complications Documentation Area
• Comment Area
• Relief Area including start and end times – there should be multiple areas if your practice includes CRNAs, AAs, and/or Resident
• Provider(s) Signature, Date, and Time – there should be multiple areas if your practice includes CRNAs, AAs, and/or Residents

A comprehensive post operative evaluation form should include:

• Respiratory Function including respiratory rate, airway patency, and oxygen saturation
• Cardiovascular Function including pulse rate and blood pressure
• Mental Status
• Temperature
• Pain
• Nausea and Vomiting
• Postoperative Hydration
• Additional Types of Monitoring and Assessment as needed
• Provider Signature, Date, and Time
  

The primary purpose of maintaining a record of anesthesia services provided is to document an individual patient’s response to anesthesia and surgery.  This information is permanently stored in the medical record for the benefit of the patient and to provide other medical practitioners with information that may be pertinent to the patient’s care.  For the anesthesia provider, a secondary but critical purpose for maintaining a record of anesthesia care is to provide documentation for anesthesia services, intra-operative and post-anesthesia care and, if applicable, all elements of medical direction.  It does not matter if your practice has 1 form for all stages of care or if you have specific forms for each stage of care.  The design and content of the form(s) will determine the value it adds to your practice.  The best practices have standardized forms across all facilities that are comprehensive including all key elements for each stage of care, easy to use, and concise. 
This article was contributed by ACE Consultant Lynette Peterson.  Lynette is a seasoned process and business analyst as well as a coding professional specialized in anesthesia.