OIG Work Plan: What Coders Should Watch
The Office of Inspector General (OIG) regularly publishes its Work Plan to outline areas it will audit, evaluate, or investigate. While topics shift throughout the year, certain themes appear consistently—especially ones that impact medical coding, documentation, and reimbursement accuracy.
Below is a distilled, coder-friendly guide.
✅ 1. High-Risk E/M Services
E/M remains an OIG hotspot every year.
Watch for:
Upcoding or unsupported levels of service
Split/shared visit compliance (especially in outpatient settings)
Prolonged service use (time documentation must be exact)
Telehealth E/M documentation completeness
Coder Tip: Ensure medical decision-making or time documentation fully supports the coded level.
✅ 2. Telehealth Services
Since expansion during the public health emergency, telehealth remains heavily scrutinized.
Focus areas:
Appropriate POS and modifier usage
Valid patient/provider locations
Service equivalency and documentation (e.g., audio-only rules)
Preventive telehealth misuse
Coder Tip: Watch for mismatch between documented modality vs. billed service.
✅ 3. Medicare Advantage (Risk Adjustment)
OIG continues to audit risk-adjusted diagnoses.
What coders should know:
Every HCC diagnosis must be supported in the encounter
No “historical” conditions unless documented as active/monitored/treated
Provider assessment must be explicit
Coder Tip: Query when conditions appear without assessment/plan.
✅ 4. Incident-To and Split/Shared Services
These areas are frequently targeted for miscoding.
Key risks:
Incorrect billing provider (supervision rules violated)
Shared visit rules changing under new E/M guidelines
Services performed by staff but billed at full provider rate
Coder Tip: Make sure services billed under physicians meet all “incident-to” criteria.
✅ 5. Modifier Misuse
The OIG often cites problems with:
Modifier 25 (significant, separately identifiable E/M)
Modifier 59 and XS/XE/XU (distinct procedural service)
Modifier 24 (unrelated E/M during postoperative period)
Coder Tip: Ensure documentation clearly supports the distinction or separate work.
✅ 6. Behavioral Health Services
Demand has increased—and so has scrutiny.
Hotspots:
Telepsych visits
Group therapy documentation
Incorrect time-based coding
Non-certified provider billing
Coder Tip: Double-check provider credentials and time documentation.
✅ 7. Laboratory and Diagnostic Testing
Overutilization and unsupported tests are common audit areas.
Watch for:
Medical necessity
Panel vs. individual test billing
Duplicate testing
Genetic test documentation requirements
Coder Tip: Verify that documentation supports each ordered test.
✅ 8. Opioid-Related Services & Medication-Assisted Treatment (MAT)
OIG continues to monitor:
MAT services (e.g., buprenorphine) documentation
Drug testing overuse
Frequency of opioid prescriptions
Coder Tip: Ensure frequency and purpose of testing/treatment is documented clearly.
🎯 How Coders Should Use the OIG Work Plan
Audit your own claims in the highlighted areas
Ensure documentation templates support new requirements
Flag provider education needs early
Monitor updates—OIG adds items monthly
Learn Medical Coding Course in Hyderabad
Read More
How to Stay Compliant with Payers
The Role of Medical Coding in Audits
HIPAA and Medical Coding: What You Should Know
📊 Compliance & Regulation in Medical Coding
Visit Our Quality Thought Institute
Subscribe by Email
Follow Updates Articles from This Blog via Email
No Comments