DRG issues caught by the eye of OIG
The Office of Inspector General (OIG) is reviewing Medicare?s billing and reimbursement integrity for two diagnosis-related groups (DRG) or DRG issues, 1) inpatient claims for kwashiorkor diagnosis, 2) mechanical ventilation in the 2017 Work Plan.
Kwashiorkor is a severe protein malnutrition that usually ?affects children living in tropical and subtropical parts of the world during periods of famine or insufficient food supply,? according to studies. Inappropriate payments to hospitals are prevalent, according to OIG.
Mechanical ventilation inpatient claims are much more common, and so is erroneous billing.
According to For the Record, ?To qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation. An OIG audit for 2009?2011 revealed an error rate of greater than 95% in mechanical ventilation billing to Medicare.?
If you are processing inpatient claims, be sure to audit your healthcare organization?s physician documentation and DRG reporting for kwashiorkor and mechanical ventilation claims before the OIG audits you.