Find-A-Code Focus Newsletter

2016 OIG Workplan: Hospital Highlights

By Bonnie G. Schreck, BS, CCS, CPC, COC, CP
January 19, 2016

The OIG, or Office of the Inspector General, is a department of Health and Human Services (HHS), that was organized to protect the integrity of HHS programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse, identifying opportunities to improve program efficiency and effectiveness, and holding responsible individuals and groups who do not meet program requirements or who violate Federal healthcare laws.

Every year, the Workplan determines the areas that will be reviewed by the department. Adjustments are made throughout the year to anticipate and respond to developing issues with the resources available. Risk areas in Federal programs are identified and most in need of attention.

For 2016, below are a few of the hospital issues that will be highlighted:

Inpatient claims for mechanical ventilation

Medicare payments for inpatient hospital claims with certain Medicare Severity-Diagnosis Related Group (MS-DRG) that require mechanical ventilation to determine whether hospitals’ DRG assignments and the Medicare payments for these were appropriate. Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. For certain DRGs to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation; the review will include claims for beneficiaries who received over 96 hours of mechanical ventilation.

 Selected inpatient and outpatient billing requirements

Review of Medicare payments to acute care hospitals to determine hospitals’ compliance with selected billing requirements and the recommended recovery of overpayments. Prior OIG audits have identified risk areas for Medicare billing requirements noncompliance. The focus of the review will be on those hospitals with claims that may be at risk for overpayments.

 Nationwide review of cardiac catheterizations and endomyocardial biopsies

Review of Medicare payments for right heart catheterizations and endomyocardial biopsies billed during the same operative session and determine whether hospitals acted in accordance with Medicare billing requirements.

 Payments for patients diagnosed with kwashiorkor

Review Medicare payments made to hospitals for claims that include a diagnosis of kwashiorkor to determine whether the diagnosis is adequately supported by documentation in the medical record. A diagnosis of kwashiorkor on a claim substantially increases the hospitals’ reimbursement from Medicare. Kwashiorkor is a form of severe protein malnutrition that generally affects children living in tropical and subtropical parts of the world during periods of famine or insufficient food supply and typically not found in the United States. Prior OIG reviews have identified inappropriate payments to hospitals for claims with a kwashiorkor diagnosis.

Other topics up for review in 2016 by the OIG are:

 Bone marrow or stem cell transplants

 Medicare payments during MS-DRG payment window

 Duplicate graduate medical education payments

To get more information on the OIG Workplan, click on the following link:

http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf


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