Is the Patient Truly Ill? Why Random Audits Could Prevent Recoupment

by  By Ronald Hirsch, MD, FACP, CHCQM, CHRI

Originally printed August 10, 2022 in

Recently, the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) released an interesting audit. They audited billing of critical care visits by physicians who are employed by Lahey Clinic in Massachusetts. As usual, they planned to audit 100 admissions but then, as they describe, because of the resource-intensive effort required to perform a medical review, they lowered that down to 10 admissions, although those 10 admissions included 92 critical care visits. Now, this may have actually been a good thing for Lahey because since they did not use their original sample size, it appears the OIG decided not to extrapolate their findings. Overall, in this audit, the OIG found that 61 percent of critical care claims were improper.

Now here is the important part: From the examples the OIG provided, I agree with their findings, as did Betsy Nicoletti, a nationally renowned expert on physician coding and documentation. From the descriptions provided in the report, the physicians clearly provided regular hospital visits that were not even close to critical care. The message here is that if your organization does billing for physicians, it would be wise to perform some random audits of critical care visits billed with CPT codes 99291 and 99292 to ensure the patient was truly critically ill.

Two weeks ago, I talked about the Centers for Medicare & Medicaid Services (CMS) proposal to establish a new hospital type, the rural emergency hospital that will provide ED care and observation services. Well, on a CMS call last week we got a few more details. I noted that these hospitals will get a monthly payment from CMS in addition to getting their OPPS payments increased by five percent. It turns out that for 2023, the per-hospital monthly payment will be $286,294. That means each would get over $3.2 million a year in addition to any revenue generated by patient care. That seems to me to be a lot of money, but will it be enough to persuade rural hospitals that are on the brink of failing to convert to a rural emergency hospital? Only time will tell.

The other interesting thing about these facilities is that CMS has proposed to limit the annual patient encounter to under 24 hours. And on the open-door forum call we found out that CMS has proposed that limit but surprisingly they don’t know which patients go into that calculation and are asking for suggestions. If they limit it to only observation patients, that is going to be a problem. It’s pretty rare in normal hospitals to have an average observation time of 24 hours.  We will see what CMS decides. I am hoping, for the sake of these facilities, that CMS includes all patients receiving services.

I will also note that in the 2023 OPPS proposed rule, CMS discusses creating a new payment category, paying for software as a service. In short, this is when a test result of some type, be it radiology images or lab results, are input into a computer program that then produces a result that provides new, additional information used to care for the patient. For example, HeartFlowFFR uses CT scan images to characterize blood flow in the coronary arteries and LiverMultiScan uses MRI images to characterize the cause of liver disease. CMS specifically notes that they are concerned about the potential for such products to have unintentional bias in their software algorithms and they want to ensure they are paying for a product that is equally accurate for all patient populations without bias.

Good for CMS. They are serious about their goal of health equity.


Is the Patient Truly Ill? Why Random Audits Could Prevent Recoupment. (2022, August 25). Find-A-Code Articles. Retrieved from

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