Associate Director’s Note: Take advantage of government reports for CDI focus points
Back in the day (oh, about nine years or so ago), I found myself tucked into my office late into a Thursday evening skimming the tome that was the Office of the Inspector General’s annual Work Plan release. The Work Plan is—just as its name implies—an outline or agenda of investigations the OIG intends to review in the coming year. In 2007, Work Plan focus areas included DRG upcoding, unbundling hospital outpatient services, and inpatient-only services performed in the outpatient setting.
Its 2016 Work Plan includes a number of items pertinent for CDI professionals including ongoing investigations into MS-DRG assignment associated with mechanical ventilation and kwashiorkor claims.
In order for certain mechanical ventilation MS-DRGs to qualify for coverage, the patient must receive 96 or more hours of treatment, so the documentation of intubation and extubation needs to be as thorough as possible.
Medicare paid more than $700 million for kwashiorkor claims during calendar years 2010 and 2011 alone. Since the rare form of severe protein malnutrition typically only occurs in third-world, famine-struck countries, claims for the condition have been on the OIG’s radar for the past few years. Type the term in the ACDIS search engine to read up on nearly a dozen cases of OIG take backs—including $3,189,884 in kwashiorkor-related claims from Des Moines-based Mercy Health Network
A new investigation this year turns the OIG’s investigative light onto CMS. CDI professionals have been expanding into quality record reviews in the past few years as hospital value-base purchasing measures gain increased influence on facility reimbursement. In 2016, the OIG will look to determine the accuracy and completeness of the data CMS is collecting and to examine the actions the agency has taken as a result.
As you’ll read below in this edition of CDI Strategies, CMS continues to tinker with its 2-midnight rule pertaining to when a physician can technically admit a patient to the hospital. Last year, the agency allowed inpatient admission as long the physician felt (and the record reflected) that the patient would require an inpatient stay that lasts more than two midnights. In the recently released, Outpatient Prospective Payment System (OPPS) final rule, however, physicians can admit the patient to the hospital based on their assessment of the patient and the documentation of the clinical indicators supporting that assessment. Although compliance with the 2-midnight rule typically falls to the case management and utilization review teams, CDI professionals may be called upon to help clarify documentation or brainstorm simple solutions to help.
These are just a few highlights of the more than 80 Work Plan pages. It’s worth a quick read to make sure that none of your facility’s common conditions or practices are on this list. If they are, it might be worth taking a closer look to see if your documentation improvement team might be able to help address them before the OIG comes to take a peek.