Lessons Learned from OIG Audits: Modifier 62

 

March 24, 2023 | By Jennifer McNamara, CCS, CPC, CDEO, CPMA, CRC, COSC, CGSC, COPC, AAPC Approved Instructor | CEO, Healthcare Inspired, LLC

One modifier that often raises eyebrows and questions is Modifier 62. This modifier can impact reimbursement and compliance, making it a focal point for audits by the Office of Inspector General (OIG).

Modifier 62: Two Surgeons, One Goal

Modifier 62 is used to indicate when two surgeons collaborate on a single procedure, sharing responsibilities to ensure optimal patient care. OIG audits reveal that proper documentation and clear communication are essential when using Modifier 62. What can we learn from a recent audit?

In 2022, the findings from 100 statistically sampled services indicate a significant risk of non-compliance with Federal requirements in physician surgical services. Out of the 100 sampled services, 69 did not comply, leading to overpayments of $31,545. In addition, when looking at the results of the larger dataset, it was estimated that Medicare made $4.9 million in improper payments for physician surgical services during the audit period. This poses a substantial risk for payers like Medicare, as they are disbursing funds for services that did not meet the necessary criteria.

From a payer perspective, it highlights the importance of implementing robust system controls to identify and prevent such improper payments. To better control the risk of misuse in modifier 62, insurance companies can implement several measures.

First, they can enhance their claim review processes by incorporating automated systems that flag potentially erroneous claims using modifier 62. These systems can analyze billing patterns and identify unusual billing practices for further investigation. Second, insurance companies can conduct regular audits of providers to ensure compliance with proper billing procedures. These audits can help identify any trends of misuse and allow for timely intervention and corrective actions. Third, offering educational resources to healthcare providers regarding proper billing practices for modifier 62 can help improve awareness and reduce unintentional errors. By combining these approaches, insurance companies can significantly reduce the risk of misuse and improve overall claim accuracy.

For physician practices, these findings emphasize the need to ensure accurate and proper billing practices. To minimize the risk of non-compliance and overpayments, physician practices should review and update their billing processes regularly, ensuring that services are billed with the correct modifiers and codes. Additionally, it’s crucial for physician practices to stay informed about the latest Federal requirements and guidelines to avoid errors in billing. Regular internal audits and compliance training for staff can also play a significant role in reducing the risk of improper payments and enhancing overall billing accuracy. By taking proactive steps, physician practices can mitigate the risk of financial loss due to non-compliant billing practices.

1. Detailed Documentation: The OIG audits emphasize the importance of comprehensive documentation outlining each surgeon’s role and contribution during the procedure. This documentation should highlight the medical necessity for two surgeons and describe the specific tasks performed by each.
2. Shared Responsibilities: Audit findings underscore the need for accurate reporting of the surgeons’ distinct contributions. This highlights the significance of defining clear boundaries and ensuring that each surgeon’s actions are distinct and separately identifiable.
   
3. Billing Transparency: OIG audit results highlight the necessity of transparency in billing practices. Ensure that billing accurately reflects the shared nature of the procedure and the contribution of each surgeon.

Key Takeaways for Healthcare Providers

1. Documentation is King: Comprehensive and accurate documentation is a common thread in accurately reporting Modifier 62. Thoroughly detail the contributions of involved parties, the medical necessity for collaboration or split services, and the distinct tasks performed.
2. Compliance and Transparency: Audits underscore the importance of transparent billing practices that accurately reflect the collaborative or split nature of services. Billing should align with documentation and coding guidelines.
3. Educate and Train: Stay updated on the latest coding guidelines and communicate them effectively to your healthcare team. Offering training on proper modifier use and documentation can mitigate compliance risks.

By learning from these audit insights, healthcare providers can navigate the modifier maze with confidence and integrity.

Your next steps:

1. Contact NAMAS for information about customized staff and provider training.
2. Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
3. Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
4. Check out the agenda for the 15^th Annual NAMAS Auditing & Compliance Conference and register to attend!

NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956.  With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.

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