Health Information Management

News: OIG targets MS-DRGs upcoding in 2009 Work Plan

CDI Strategies, October 29, 2008

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Since October 1, 2007, Medicare providers have been adapting to a revised hospital inpatient reimbursement system, otherwise known as Medicare Severity DRGs (MS-DRGs).

One year later, the Office of the Inspector General (OIG) released its 2009 Work Plan and included an item that says they will “examine coding trends and patterns under the new system and determine whether specific MS-DRGs are vulnerable to potential upcoding.”

This is an expected item on the Work Plan, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, corporate director coding, HIM, compliance, at Catholic Healthcare West in San Francisco.

“It’s a good message to tell providers to be checking in this area because they’re [OIG] going to be checking in this area,” she says.

The Work Plan outlines the OIG’s investigational priorities for the coming year. “Our targeted audits and evaluations continue to identify significant improper payments and problems in specific parts of the [Medicare] program,” the Work Plan states.

All leaders across the healthcare continuum can glean valuable insight from the Work Plan, says Christine Bachrach, chief compliance officer and senior vice president at HealthSouth in Birmingham, AL.

“Diagnosis codes didn’t impact payment before but it does now,” says Bachrach. “The OIG will use this examination of the system as a way of identifying patterns. If they find a pattern where certain codes increase and therefore payments increase, they will investigate further.”

CDI specialists should work with compliance officers and auditing directors, as these key stakeholders integrate OIG priorities into facility goals for 2009. Furthermore, CDI leaders can add Work Plan information to their educational arsenal as they communicate with coding staff members about MS-DRG concerns.

After having the same DRG system since the ‘80s, they will likely find issues that the staff needs to address before the OIG addresses them, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, senior coding and chargemaster consultant for QHR in Brentwood, TN.

The 2009 Work Plan lists nine new audits affecting hospitals and 11 ongoing examinations, for a total of 20 audits.

The nine new Medicare hospital audits include:


  • Additional Part A Medicare capital payments for extraordinary circumstances
  • Hospital ownership of physician practices
  • Inpatient hospital payments for new technologies
  • Inpatient rehabilitation facility payments
  • Inpatient psychiatric facility emergency department adjustments
  • Reliability of hospital-reported quality measure data
  • Oversight of hospitals’ compliance with the Emergency Medical Treatment and Labor Act (EMTALA)
  • Coding and documentation changes under the Medicare severity-DRG (MS-DRG) system.
  • Serious medical errors (“never events”)

    To read the full plan, click here.

    Join HCPro for a 90 minute audio conference regarding the 2009 OIG Work Plan on Tuesday, November 4, 1 p.m. (EST). To learn more, click here.




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