OIG Recommends Targeted Audits of MS-DRGs

Last week, the OIG released a report on Part A claims for inpatient hospital stays from FY 2014 through FY 2019. The report indicates that approximately 50% of Medicare payments for inpatient hospital stays were based on the highest severity MS-DRG.  These payments totaled $54.6 billion dollars. The report also highlighted some notable trends:

  • The overall number of claims at the highest MS-DRG has risen 20%.
  • The average length of stay for the highest MS-DRGs has decreased.
  • Over half of the claims contained only 1 qualifying diagnosis for the highest MS-DRG.
  • The most frequently billed MS-DRG was severe sepsis with a major complication (MS-DRG 871).
  • Certain MS-DRGs have been identified as frequently having shorter than the average length of stay including; heart failure and shock (MS-DRG 291), pneumonia (MS-DRG 193), and renal failure (MS-DRG 682).

The OIG stressed that claims for the highest level MS-DRGs are susceptible to inappropriate billing patterns including up-coding.  They recommended CMS initiate targeted reviews of MS-DRGs and specifically include hospitals who frequently bill the highest MS-DRG levels. We recommend hospitals perform internal analysis of their MS-DRG billing as well as conduct internal reviews of the MS-DRGs specifically identified in the OIG report as well as any other frequently billed highest level MS-DRGs.

HBE’s team of coding and compliance experts is available to assist you with data analysis, external reviews of your documentation, coding and reimbursement as well as providing customized education and training for your staff.  We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.  

You can read the complete report from the OIG here: https://oig.hhs.gov/oei/reports/OEI-02-18-00380.pdf

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel.

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