New Role for Mid-Revenue Cycle Professionals: Patient Advocates

OIG report points to need for helping victims of abuse and neglect, through coded data

By Brian Murphy

While you’re looking for diagnoses and procedures to clarify and code to their highest level of specificity you should also be looking out for the best interests of the patient.

That includes evidence of suspected abuse or neglect, either from a domestic source or from caregivers.

According to a recent OIG report CMS could be doing more to fix a serious problem.

The OIG last week released the results of a targeted audit of more than 30,000 Medicare claims for services provided between January 1, 2019, and December 31, 2020. These claims contained diagnosis codes indicating “the treatment of injuries potentially caused by abuse or neglect of Medicare enrollees.” 69% of the claims were from the outpatient setting, the remaining 31% inpatient.

The OIG estimated that 27,522 of these 30,258 flagged claims were supported by medical records that “contained evidence of potential abuse or neglect.” It further estimated that, of the claims in its sampling frame:

  • 2,320 cases of abuse or neglect were allegedly perpetrated by health care workers
  • 3,546 cases of abuse or neglect were related to incidents that occurred in medical facilities
  • 7,298 of these cases were related to incidents not reported to law enforcement

The OIG flagged many diagnosis codes for review, but some high prevalence examples included:

  • T7601XA, Adult neglect or abandonment, suspected, initial encounter
  • T7411XA, Adult physical abuse, confirmed, initial encounter
  • T7621XA, Adult sexual abuse, suspected, initial encounter
  • T7491XA, Unspecified adult maltreatment, confirmed, initial encounter

The OIG presented four recommendations to CMS:

  1. Conduct data analyses to identify trends and high-risk areas in Medicare claims containing diagnosis codes indicating potential abuse or neglect
  2. Provide the results of the analyses to QIOs and Medicare Program Integrity contractors so that they can conduct targeted claim reviews to identify patterns of unreported incidents of potential abuse or neglect
  3. Develop and share guidance and best practices with providers to help ensure that incidents are reported in compliance with State mandatory reporting laws
  4. Consider the results of targeted claims reviews when assessing whether the existing conditions of participation requirements for reporting abuse or neglect of Medicare enrollees should be strengthened

CMS agreed to all of these recommendations, and noted that it will “develop and share guidance with providers on reporting instances of potential abuse or neglect.” So expect that guidance to be hitting in the coming months.

Unfortunately doing the right thing can land you in hot water in an increasingly litigious environment. But it doesn’t mean you shouldn’t try. Also, the Medicare and Medicaid Conditions of Participation mandate the protection of Medicare enrollees from abuse and neglect.

Have you encountered evidence of patient abuse/neglect during your chart reviews or coding work?

Does your organization have a policy for how to handle reporting these situations?

Worth thinking about.


OIG report (summary), “CMS Can Do More To Leverage Medicare Claims Data To Identify Unreported Incidents of Potential Abuse or Neglect”:

Full report:

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