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DRGs targeted by the OIG

Compliance Monitor, February 25, 2001

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Compliance professionals should include high-risk diagnosis related groups (DRG) in their compliance-monitoring plans. The Office of Inspector General (OIG) noted in a series of reports that the DRG system is vulnerable to abuse through upcoding of certain DRGs. The OIG found that although hospital payment systems are functioning well, there are significant vulnerabilities to upcoding that can be avoided. The OIG believes that the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration, is not performing sufficient monitoring of DRG coding to detect troublesome DRGs. In numerous audit reports, the OIG has recommended to CMS that it should identify hospitals with aberrant patterns of DRG upcoding. CMS agreed to conduct analysis of discharge patterns.

1. The OIG identified several DRGs with abnormally high billings that CMS will be monitoring in 2001. Compliance professionals should ensure the following DRGs are part of the 2001 audit plan: DRG 79 - Respiratory Infection; DRG 296 - Nutritional & Miscellaneous Metabolic Disorders; DRG 416 - Septicemia; DRG 475 - Respiratory System Disorders with Ventilator Support; and DRG 14 - Specific Cerebrovascular Disorders.

2. Hospital compliance professionals need to be proactive and take steps to ensure that medical records properly support billings for all DRGs in addition to the DRGs specifically targeted by the OIG.

3.Regular checks of the OIG Web site should be an integral part of the compliance officer's function. Information on areas of OIG focus can be found at http://www.oig.hhs.gov/.

By Hank Vanderbeek, MPA, CIA, CFE
IRP, Inc.

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