OIG report on mechanical ventilation raises compliance red flags

By Brian Murphy

 

Medicare improperly paid hospitals an estimated $79 million for patients who received mechanical ventilation.

 

Is your healthcare organization among them?

 

The OIG released a new report taking aim at MS-DRGs 207 and 870. It selected for review a random, stratified sample of 250 claims submitted between 2015-2021 with payments totaling $11M.

 

Reporting MS-DRGs 207 and 870 requires a handful of components, including the right procedure and diagnosis codes but also that the patient receive 96 hours or more of mechanical ventilation. 

 

The OIG found that some of these patients did not. Though not an alarmingly high number. 

 

For 233 of 250 sampled claims, Medicare payments to hospitals complied with requirements. 17 contained incorrect procedure or diagnosis codes, per the OIG. That’s a 93% accuracy rate, and you can bet the “stratified” sample was chosen with intent. Not  nearly as bad as other OIG audits (see severe malnutrition), but if you’re not counting your vent hours closely you might be the subject of the next audit. 

 

For eight sampled claims, hospitals incorrectly used procedure code 5A1955Z for more than 96 hours of mechanical ventilation when enrollees received less.

 

For nine sampled claims, hospitals used incorrect diagnosis codes or incorrectly used a procedure code that was not related to mechanical ventilation. 

 

The result was incorrect assignment of MS-DRGs 207 or 870, resulting in $382,032 of overpayments. 

 

I always find the examples instructive.

 

For one enrollee, the physician’s notes and ventilation time logs showed that the enrollee had received 94 consecutive hours of mechanical ventilation. The hospital used procedure code 5A1955Z on the claim; instead, the hospital should have used procedure code 5A1945Z (24 to 96 hours). The claim was assigned incorrectly to MS-DRG 870 rather than MS-DRG 871, resulting in an overpayment of $10,192.

 

In a second example, a hospital submitted a claim with principal diagnosis code J96.00 (“acute respiratory failure, unspecified whether with hypoxia or hypercapnia”). A review of the medical records showed that the hospital should have used principal diagnosis code I12.0 (“hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease”). The claim was incorrectly assigned to MS-DRG 207 rather than MS-DRG 682 (“Renal failure with MCC), resulting in an overpayment of $33,060.

 

On the basis of this sample audit, the OIG estimated that Medicare paid hospitals $79.4 million over a six-year period.

 

Medicare won’t recoup this extrapolated amount, though the OIG will likely point to a sizable finding in its annual report to Congress. Even though the hospitals in error did confirm that they used incorrect procedure or diagnosis codes and generally attributed the improper billing to incorrectly counting the hours, or to “clerical errors” in selecting procedure or diagnosis codes.

 

The OIG recommended that CMS recoup the $380K and educate hospitals. CMS concurred. 

 

Overall, worth reading the report.  I’ve included the link below and some definitions.

 

References

 

• DRG 207: Respiratory system diagnosis with ventilator support > 96 hours

 

• DRG 870: Septicemia or sepsis with mechanical ventilation > 96 hours 

 

• OIG, Medicare Improperly Paid Hospitals an Estimated $79 Million for Enrollees Who Had Received Mechanical Ventilation: https://oig.hhs.gov/documents/audit/9957/A-09-22-03002.pdf