News: Incorrect acute stroke codes result in $14 million inaccurate payments, OIG finds

An audit performed by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) found that incorrect acute stroke diagnosis codes submitted by traditional Medicare providers resulted in millions of dollars in increased payments to Medicare Advantage organizations.

The audit involved 582 individuals from 2014-2015 who were:

• Eligible for Medicare,
• Covered under traditional Medicare one year,
• Chose to enroll in Medicare Advantage the following year, and
• Received one instance of high-risk acute stroke diagnosis

Through data mining, the OIG identified several diagnosis codes that were at high risk of being miscoded and resulting in inaccurate payments. This audit focused only on selected acute stroke diagnosis codes that were reported on the physician’s claim without being reported on a corresponding inpatient claim. The record reviews aimed to determine whether the medical record supported the submitted diagnosis codes.

According to the OIG’s findings, almost all of the selected acute stroke diagnosis codes that physicians submitted under traditional Medicare and that CMS later used to make payments to Medicare Advantage organizations on behalf of the transferred enrollees failed to comply with federal requirements. For 580 of the 582 enrollees, the medical records did not support the documented acute stroke diagnosis codes.

The errors occurred from physicians submitting incorrect acute stroke diagnosis codes on claims billed under traditional Medicare, but went unnoticed during the patient’s transfer to Medicare Advantage. The OIG states that this happened because CMS did not have policies to identify beneficiaries who transferred or procedures to evaluate whether the acute stroke diagnosis codes complied with federal requirements. As a result, the OIG estimates CMS made inaccurate payments of $14.4 million to Medicare Advantage organizations.

The OIG recommends that CMS do the following:

• Educate physicians on how to correctly submit acute stroke diagnosis codes
• Develop and implement policies and procedures to identify beneficiaries transferring from traditional Medicare to Medicare Advantage
• Evaluate whether the acute stroke diagnosis codes submitted comply with federal requirements

Editor’s note: The OIG audit report can be found here. To read more about the perils of provider self-coding, click here. To learn more about the documentation and coding nuances of acute strokes, click here.