OIG COMPLIANCE PROGRAM:
  Office of Inspector General — monitors Medicare/Medicaid fraud
  Work Plan: annual list of audit targets
  Common issues: upcoding, unbundling, medically unnecessary services

UPCODING: billing higher-level code than documented
  Example: billing 99215 (high complexity E&M) when 99213 warranted
  Result: overpayment, potential fraud and abuse charges

DOWNCODING: billing lower than documented
  Leaves money on table, not technically illegal but poor practice

UNBUNDLING: billing components separately when bundled code exists
  Example: billing each step of laparoscopic cholecystectomy separately
  Instead: use single 47562 code

MODIFIER MISUSE:
  Modifier 25: significant, separate E&M same day as procedure
    Must document why E&M was above and beyond pre/post-op care
  Modifier 59: distinct procedural service
    Use only when no more specific modifier applies (XE, XS, XP, XU)
  Modifier 51: multiple procedures (list highest RVU first)

RAC AUDITS (Recovery Audit Contractor):
  Review claims for improper payments
  Lookback: 3 years
  Common targets: MS-DRG validation, medical necessity, duplicate billing

STARK LAW and ANTI-KICKBACK:
  Stark: prohibits physician self-referral for designated health services
  Anti-Kickback: prohibits remuneration for Medicare/Medicaid referrals
  Civil Monetary Penalties: up to $10,000 per false claim + treble damages

NEW 2021 E&M RULES (Office/Outpatient):
  Level determined by EITHER:
    Medical Decision Making (MDM) complexity, OR
    Total time on date of encounter

  MDM COMPONENTS (need 2 of 3):
    Number and complexity of problems
    Amount/complexity of data reviewed
    Risk of complications/morbidity

  LEVELS (99202-99215):
    99202/99212: Straightforward MDM or 15-29 min
    99203/99213: Low MDM or 30-44 min
    99204/99214: Moderate MDM or 45-59 min
    99205/99215: High MDM or 60-74 min

  NEW vs ESTABLISHED:
    New: not seen by physician (or same group/specialty) in 3 years
    Established: seen within 3 years

INPATIENT E&M (99221-99223 admission, 99231-99233 subsequent):
  Still uses 3-key-component method (history, exam, MDM)
  All 3 required for initial hospital (99221-99223)
  2 of 3 required for subsequent (99231-99233)