News: OIG findings reflect poor clinical documentation follow through

In two recent findings from the Office of the Inspector General (OIG), improper documentation may have led to inaccurate claims submission and associated payments.

In the first case, the OIG found that Medicare incorrectly paid hospitals for patients who did not actually receive 96 or more hours of mechanical ventilation—only 14 of the 377 claims reviewed correctly assigned ICD-9 code 96.72—resulting in more than $7 million in overpayments.

• 96.70, Continuous invasive mechanical ventilation of unspecified duration
• 96.71, Continuous invasive mechanical ventilation for less than 96 consecutive hours
• 96.72, Continuous invasive mechanical ventilation for 96 consecutive hours or more

The facilities attributed the errors to incorrectly counting the number of hours of mechanical ventilation or clerical errors in selecting the appropriate procedure code, the OIG wrote. Mechanical ventilation was a listed as a target area list in the OIG’s Fiscal Year 2013 Work Plan.

Code assignment needs to be based on hours, not days, and the physician needs to document the exact dates and times whenever intubation or extubation takes place.

“The duration of mechanical ventilation is highly scrutinized,” says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc. in Fort Walton Beach, Fla., in a JustCoding.com article. Coders shouldn’t solely rely on physician orders when calculating duration. Instead, they should also use respiratory therapy notes and progress notes, which sometimes span multiple days in the record.

Physicians may write, time, and date an order for extubation, and the patient may not actually undergo the process until an hour or more later. “It’s not when the physician writes the order—it’s when the patient is extubated,” he adds.

The OIG recommended that CMS direct its contractors to review any claims where 96.72 was used in association with a patient who had a length of stay of four days or less to recover overpayments.

In the second case, the OIG found that Bravo Health Pennsylvania, Inc., submitted invalid diagnoses to CMS for use in its risk score calculations for the 2007 calendar year, resulting in an estimated $22 million in overpayments. They found that the documentation either did not support the associated diagnosis, did not include the provider’s signature, or simply did not include any documentation related to the associated diagnosis.