OIG gets proactive in 2010 Work Plan

Hospital readmissions, adverse events, and issues related to the American Recovery and Reinvestment Act of 2009 are some of the highlights of the 2010 OIG Work Plan.

“These are relatively new issues so this is pretty proactive on the OIG’s part,” says Steve Miller, JD, chief compliance and privacy officer at Capital Health in Trenton, NJ.

In previous years, many of the OIG’s planned reviews were on topics that have been around for awhile.

“They’re getting a jump on these newer issues right away,” Miller says. This is a good move, he adds, because newer issues tend to present a higher opportunity for errors.

While CDI specialists need not drill down into the nuances of the OIG investigations they do need to be aware of the implications of those governmental efforts on their day-to-day documentation improvement efforts.

For example, the OIG says it’s going to look into coding and documentation changes under the Medicare Severity Diagnosis Related Group (MS-DRG) system, as recommended in a March 2005 MedPAC report. Essentially, the OIG says its going to examine coding trends and patterns to determine whether specific MS-DRGs are vulnerable to potential upcoding.

According to ACDIS’ sister publications’  analysis of the Plan, in 2004, CMS implemented an edit to reject subsequent claims for beneficiaries whom the hospital readmitted on the same day. According to the Medicare Claims Processing Manual, if a same-day readmission occurs for symptoms related to or for evaluation or management of the prior stay’s medical condition, the hospital is entitled to only one DRG group payment and should combine the original and subsequent stays in a single claim. In 2010 the OIG plans to test the effectiveness of this edit and determine the extent of oversight of readmission cases.

“It’s interesting because this is an issue that is getting more attention from CMS this year,” Miller says. In fact, in April, CMS announced a pilot program “Care Transitions” to focus on eliminating unnecessary hospital readmissions.

Sure, some people think the pile of paperwork that constitutes the Plan makes for good bedtime reading (zzzzzzzzzzzzzzzz) a brief examination of its Table of Contents under CMS on page v can give a snap shot of any potential hot topics your facility compliance officer may be thinking about.