OIG offers clinical scenarios that can illuminate your own audit vulnerabilities

The recent Office of Inspector General (OIG) audits of three acute-care hospitals offer a goldmine of clinical/coding examples that you should be using for pre-emptive audit defense. Validating DRG assignments, reviewing medical necessity documentation completeness, and educating providers before an auditor comes knocking—and uses extrapolation to greatly increase recoupments.

Here are examples taken from the audit reports of Sarasota Memorial, Jefferson Regional Medical Center, and Lehigh Valley, as covered in our recent report “Inpatient Audit Storm Clouds.”

It’s important to note that these hospitals pushed back against these findings, and in a few instances the OIG relented (though overall they are still on the hook for a combined $35M).

Two Midnight Stay for High Blood Pressure Was Not Supported

One enrollee, who had been taking medication for hypertension, presented to the Hospital with acute high blood pressure. The enrollee’s blood pressure responded to oral medications administered in the Hospital. Cardiac enzymes were negative, and the electrocardiogram was unremarkable. The enrollee was admitted for medication adjustment, and the admitting physician expected the enrollee could be discharged within 24 to 48 hours. Although the stay was billed as an inpatient admission, the medical record did not support an expectation that the enrollee would require hospital care spanning at least two midnights, as required under CMS’s Two-Midnight Rule.

Principal Diagnosis Code Not Supported

One enrollee was admitted to the Hospital with an incorrect principal diagnosis code used for pain caused by internal prosthetic devices, implants, and grafts. The actual cause of admission was a complication related to breast implants. The change in the principal diagnosis code caused a change in the DRG code, which should be reimbursed at a lower payment rate.

IRF Claim Did Not Meet Criteria

One enrollee was admitted for inpatient rehabilitation services with active and ongoing medical issues, such as pain and lethargy, which would reasonably be expected to interfere with their active participation in therapy. The initial physical therapy evaluation noted poor tolerance because of pain, and additional assessments were not performed for the same reason. The enrollee was discharged to the acute care unit of the Hospital because the enrollee could not tolerate a rehabilitation program.

Diagnosis Code with Complication or Comorbidity Not Supported

One enrollee was admitted for acute inpatient services after a fall with lower back pain. The clinical indicators, including physical exam findings, orders, and diagnostic studies, did not provide evidence of a complication or comorbidity. Consequently, the documentation justifies only a diagnosis code without a complication or comorbidity.

Admission Did Not Meet Inpatient Expectation

One enrollee was admitted for left hip and lower back pain with impaired ambulation (difficulty in walking). The enrollee was treated and evaluated by a physician, then was discharged after assessment by an occupational therapist. Documentation at the time of admission did not justify an expectation of hospital care for a period that crosses 2 midnights.

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