Elevating Orthopedic Medical Billing Insights from OIG's Audit

In a recent audit by the Office of Inspector General (OIG), Medicare's coverage of pain management procedures, specifically facet-joint interventions used to alleviate neck or back pain stemming from spinal facet joint issues, came under the microscope. The audit's primary objective was to determine whether Medicare adhered to its stringent requirements and guidance regarding these procedures.

Audit Highlights

A prior OIG audit had unearthed disconcerting findings: Medicare contractors in some jurisdictions had failed to reimburse physicians accurately for facet-joint injections. Furthermore, another audit revealed that Medicare had been improperly footing the bill for facet-joint denervation sessions. The OIG embarked on this comprehensive audit, driven by concerns about the potential overutilization of facet-joint interventions and the precedent of previous audits uncovering improper payments.

Audit Methodology

The OIG's audit spanned a comprehensive range of Medicare Part B payments to a staggering $62.2 million. These payments encompassed 425,843 claim lines for facet-joint interventions, each dated from August 1 through October 31, 2021 (audit period). These claims were grouped into 218,421 sessions, and from this vast dataset, a statistically significant sample of 120 sessions was selected for in-depth analysis. The audit focused intently on evaluating compliance with Medicare billing requirements and guidance. It's important to note that no medical review was conducted to assess the medical necessity of the interventions.

Audit Findings

Astonishingly, the audit unveiled a significant gap between Medicare's requirements and its actual practices. Among the 120 sampled sessions, only 54 were found to comply, while the remaining 66 sessions fell short of meeting one or more of Medicare's stringent requirements. This non-compliance led to improper physician payments, amounting to $18,084 for the sampled sessions alone. Extrapolating from this sample, it's estimated that Medicare made erroneous payments totaling a staggering $29.6 million for facet-joint interventions during the audit period. Additionally, 43 of the sampled sessions contained claim lines billed for therapeutic facet-joint injections. Intriguingly, 33 sessions didn't align with Medicare guidance, as they should have been billed for diagnostic rather than therapeutic facet-joint injections. Notably, this incorrect billing, while not affecting payment amounts (as Medicare pays the same for both types), underscores the intricate nature of proper billing and coding.

Recommendations and Actions

In response to these troubling findings, the OIG made recommendations to rectify the situation. The Centers for Medicare & Medicaid Services (CMS) were urged to take measures to recover the $18,084 in improper payments made to physicians for the 66 sampled sessions. Furthermore, CMS was strongly encouraged to foster the development of collaborative training programs across all Medicare Administrative Contractor (MAC) jurisdictions. These programs would focus on the rigorous Medicare requirements for facet-joint interventions, potentially preventing erroneous payments totaling an estimated $29.6 million in future audit periods. Lastly, CMS was advised to devise practical solutions that prevent diagnostic facet-joint injections from being billed as therapeutic ones. This may entail additional education initiatives or guidance updates to address this complex billing issue.



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