Compliance plans are critical to making sure your organization is mitigating risk. The Office of Inspector General (OIG) recommends that you audit a minimum of 10 professional encounters per year per physician—but if you’re not going above and beyond that by performing focused audits, you’re putting your practice at risk by ignoring everything else.  Not to mention, you may be missing opportunities from under-coding.

Each year OIG publishes their Work Plan detailing exactly what they will be focusing on in the coming year. This is a goldmine of information to help compliance officers stay ahead of the game. However, because the Work Plan is so extensive, too many compliance officers simply don’t know where to start and ignore this valuable resource.

To give you a jumpstart and make sure 2020 is the year you make the most of your compliance efforts, we’ve narrowed down the OIG Work Plan to 12 key categories in the professional arena. These categories give you a valuable starting place for building a compliance plan that protects your organization in areas the government is particularly concerned with examining this year.

What’s the best way to use this list of 12 categories? Consider your billing volume. Do you bill a significant amount within any of these categories? If so, they should be a part of your focused compliance plan as they will be areas of particular audit focus for OIG this year. Do you have more then one category with significant billing? Prioritize your audit efforts based on the area with the highest billing first and attack them one-by-one until you’ve tackled them all.

By taking an intentional, focused approach to your compliance planning you can make the most of your efforts. Now, on to the 12 key categories!

#1: Medicare Payments for Chronic Care Management

Chronic Care Management (CCM) is the non-face-to-face services provided to Medicare beneficiaries who have multiple significant chronic conditions such as Alzheimer’s disease, arthritis, cancer, diabetes, etc. that place the patient at a significant risk of death, acute exacerbation/decompensation, or functional decline. The Office of Audit Services (OAS) will be evaluating whether payments for CCM services were in accordance with Medicare requirements.

#2: Medicare Payments for Transitional Care Management

Transitional Care Management (TCM) includes services provided to a patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision-making during transitions in care from an inpatient hospital setting, partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting. OAS will be evaluating whether payments for TCM services were in accordance with Medicare requirements starting.

#3: Medicare Part B Payments for Psychotherapy Services

Medicare Part B covers psychotherapy services, which is the treatment of mental illness and behavioral disturbances in which a physician or other qualified healthcare professional establishes professional contact with a patient and, through therapeutic communication and techniques, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development. OAS will be reviewing Part B payments for psychotherapy services to determine whether they were allowable in accordance with Medicare documentation requirements.

#4: Medicare Part B Payments for End-Stage Renal Disease Dialysis Services

Medicare Part B covers outpatient dialysis services for beneficiaries diagnosed with end-stage renal disease (ESRD), and prior OIG work identified inappropriate Medicare payments for ESRD services. OAS will evaluate whether claims for Medicare Part B dialysis services provided to beneficiaries with ESRD complied with Medicare requirements.

#5: Physicians’ Billing for Critical Care Evaluation and Management Services

Critical care is the direct delivery of medical care by a physician for critically ill or critically injured patients, and it is an exclusively time-based code. OAS will evaluate whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.

#6: Medicare Part B Payments for Podiatry and Ancillary Services

Medicare Part B covers podiatry services for medically necessary treatment of foot injuries, diseases, or other medical conditions affecting the foot, ankle, or lower leg. It does not cover routine foot-care except in specific situations. Previous OIG work identified inappropriate payments for podiatry and ancillary services so OAS will review Part B payments to determine whether podiatry and ancillary services were medically necessary and supported in accordance with Medicare requirements.

#7: Review of Medicare Part B Claims for Intravitreal Injections of Eylea and Lucentis

Medicare Part B covers ophthalmology services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member. This may include intravitreal injections of Eylea and Lucentis to treat eye diseases. OAS will review claims for intravitreal injections of Eylea and/or Lucentis and the other services billed on the same day as the injection, including evaluation and management services, to determine whether the services were reasonable and necessary and met Medicare requirements.

#8: Medicare Payments of Positive Airway Pressure Devices for Obstructive Sleep Apnea Without Conducting a Prior Sleep Study

An OIG analysis of the 2017 Comprehensive Error Rate Testing (CERT) program for positive airway pressure (PAP) device payments shows potential overpayments of $566 million.  This may be due to claims for PAP devices used to treat obstructive sleep apnea (OSA) for beneficiaries who have not had a positive diagnosis of OSA based on an appropriate sleep study. OAS will examine Medicare payments to durable medical equipment providers for PAP devices used to treat OSA to determine whether an appropriate sleep study was conducted.

#9: Review of Facet Joint Procedures

Facet joint injections are an interventional technique used to diagnose or treat back pain. Several previous reviews found significant billing errors in this area. OAS will review whether payments made by Medicare for facet joint procedures billed by physicians complied with Federal requirements.

#10: Medicare Part B Payments for Speech-Language Pathology

When Medicare payments for a beneficiary’s combined physical therapy and speech therapy exceed an annual therapy spending threshold (e.g., $2,010 in 2018), the provider must append the KX modifier to the appropriate HCPCS reported on the claim. OAS will determine whether the claims using the KX modifier adhere to Federal requirements and will also evaluate payment trends to identify Medicare payments for outpatient speech therapy services billed using the KX modifier that are potentially unallowable.

#11: Review of Medicare Part B Urine Drug Testing Services

Medicare covers treatment services for substance use disorders (SUDs), such as inpatient and outpatient services, when they are reasonable and necessary as well as clinical laboratory services, including urine drug testing (UDT), under Part B. OAS will review UDT services for Medicare beneficiaries with SUD-related diagnoses to determine whether those services were allowable in accordance with Medicare requirements.

#12: Medicare Payments for Stelara

Since 2016, total Medicare Part B payments to physicians for Stelara have increased substantially. OIG will conduct a study to (1) determine whether versions of Stelara that are typically self-injected meet the criteria for Medicare Part B coverage, (2) identify factors that may be causing the substantial growth in payments, and (3) determine whether claims for Stelara show evidence of improper billing by physicians.

There you have it!  As you’re building your 2020 compliance plan, remember the 12 key professional services areas from the OIG Work Plan to ensure you’re focusing your attention on the same areas as the OIG.

Randomly auditing 10-25 professional encounters per physician each year does little to minimize your risk if you don’t have specific things you’re looking for. This year, build a compliance plan that intentionally checks those areas we know OIG is paying particular attention to.

If you need help building your OIG Hitlist, connect with a Panacea expert by calling us at 866-926-5933 or contact us by email at

By Becky Rodrian-Jacobsen, CCS-P, CPC, CBCS, MBS, CEMC, CPEDC, BSN