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TOPIC: Conduct a review of troublesome DRGs at your facility

HIM Connection, August 16, 2003

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Since the late 1990s, the Office of Inspector General (OIG) has been concerned with a number of diagnosis-related group (DRG) coding schemes, such as DRG 79 versus DRG 89, pneumonia. The Work Plan indicates that the OIG will reexamine a number of these DRG pairs as well as a number of other DRGs for which investigations have been conducted. A recent review of the OIG Web site revealed the following DRG investigations conducted by the OIG between 1998 and 2002:

--014: Specific Cerebrovascular Disorders Except Transient Ischemic Attack

--079: Respiratory Infections and Inflammations

--121: Circulatory Disorders with Myocardial Infarction and Cardiovascular Complications

--154: Stomach, Esophageal, and Duodenal

--296: Nutritional and Miscellaneous Metabolic Disorders

--416: Septicemia

--475: Respiratory System Diagnosis with Ventilator Support

Reviews of these DRGs should be conducted within your organization if patients with these conditions frequent your facility.

The Work Plan also mentions "inaccurate coding by hospitals can lead to overpayments. We will determine coding payment error rates and incorporate the results of a recent review by quality improvement organizations." The OIG has become increasingly concerned with Medicare's improper payment rate since it began comprehensive audits of the Medicare program for billing, coding, and reimbursement accuracy in FY 1996. When the initial audit for whether Medicare contractors were correctly paying for "reasonable and necessary" services found a 14% error rate in FY1996, a slew of new payment error prevention programs and activities were put into motion. The most recent FY2002 audit revealed a 6.3% error rate.

This means that you are likely to receive inquiries from multiple sources (peer review organizations, Medicare contractors, Medicaid programs, Medicare program safeguard contractors, etc.) requesting you send "supporting documentation" for the services for which you are submitting claims. This is another strong argument for taking a careful look at your corporate compliance program and additional training as necessary for the medical records and billing staff.

This week's HIM Connection was adapted from an excerpt of the book, "The Compliance Troubleshooter: Tackling the Top 10 Compliance Challenges." Go to HCMarketplace for more information or to order for the special price of $79.

Sincerely,

Lauren McLeod
Executive Editor
lmcleod@hcpro.com

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