Knowledge Base Article

The Office of Inspector General (OIG) recently released the report Medicare Incorrectly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Hours of Mechanical Ventilation. In fact, the report indicates that in the calendar years 2009 – 2011, Medicare overpaid hospitals $7.7 million.

Background

The OIG has done prior hospital compliance reviews of claims with MS-DRGs requiring 96 or more hours of mechanical ventilation. In past reviews the OIG found erroneous claims and as such this review was performed to determine whether payments made to hospitals for MS-DRGs requiring 96 or more hours of mechanical ventilation were correct. Hospitals use procedure code 96.72 (Continuous invasive mechanical ventilation for 96 consecutive hours or more) to identify these patients. This review focused specifically on two MS-DRGs:

• MS-DRG 207: Respiratory System Diagnosis with Ventilator Support 96+ Hours and
• MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours.

Audit by the Numbers

• $12,764,239: The amount of Medicare Part A payments covered in this audit.
• 290: The number of hospitals included in this audit.
• 377: The number of inpatient claims that were selected as at risk for billing errors.
• 4 days or less: This audit reviewed claims where the length of stay was 4 days or less.
• 14: The number of records where the Medicare payment was correct.
• 363: The number of records where the Medicare payment was incorrect due to the beneficiary not receiving 96 or more hours of mechanical ventilation.
• $7,714,825: The overpayments made by Medicare to the hospitals

As part of the audit process the OIG had the hospitals conduct an internal review of the claims to determine if the services had been billed correctly. The OIG also requested that the hospital provide them with the “itemized bills and medical record documentation, including timelog for the mechanical ventilation and summary of the inpatient stay to determine whether the beneficiaries had received 96 or more hours of mechanical ventilation.”

The report indicates that “the hospitals confirmed that these claims were incorrectly billed and generally attributed the errors to incorrectly counting the number of hours that beneficiaries had received mechanical ventilation or to clerical errors in selecting the appropriate procedure code.”

Centers for Medicare and Medicaid Services (CMS) Response and Action Plan

The OIG found that CMS did not have controls in place to identify the incorrectly paid claims. Since this review, CMS “implemented a new length-of-stay edit for continuous invasive mechanical ventilation for 96 consecutive hours or more. With this edit, effective October 1, 2012, claims found to have procedure code 96.72 and a length of stay fewer than 4 days are returned to the provider for validation and resubmission.”

Is Correct Coding of Ventilator Hours still on the Radar?

Since this review focused on 2009 through 2011 calendar year claims and an edit was put in place as a control to identify incorrectly paid claims, you may be thinking that this should no longer be an issue. However, other Contractors continue to review and or monitor correct coding of ventilator hours. Before we walk through a timeline of who is reviewing this issue it is important to note that most reviewers have expanded their efforts beyond MS-DRGs 207 and 870 to also include the following MS-DRGs:

• MS-DRG 003: Ecmo or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R.
• MS-DRG 004: Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck without Major O.R.
• MS-DRG 927:Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft
• MS-DRG 933: Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft

Timeline of Review Efforts around Correct Coding of Ventilator Hours:

• Medicare Quarterly Compliance Newsletter October 2011: In the Volume 2, Issue 1 - October 2011 newsletter the CMS reported that Recovery Auditors reviewed MS-DRGs 003, 004, 207, 870, 927 and 933 due to Providers not adding the correct number of Ventilator hours during an inpatient admission. This Newsletter provides examples of their findings and education resources for hospitals.

• Cahaba GBA, the Medicare Administrative Contractor (MAC) for Alabama, Georgia and Tennessee completed a widespread probe review of MS-DRG 270 and posted the findings to their website on November 14, 2011. Their focus was on coding accuracy and medical necessity for acute inpatient hospitalization. One issue identified was that “documentation did not confirm 96 consecutive hours on ventilator support.” They took no further action as a result of this review but continue to monitor utilization through data analysis to see if further reviews are needed.

• The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is now into their 12th Edition of the Short-Term Acute Care Hospitalizations Users Guide. Ventilator Support has been an at risk target since their 6th Edition Users Guide. Internally, providers can view their report to see if they are an outlier and follow the audit recommendations in the report.

• In the 2013 OIG Work Plan, the OIG indicated that “We will review Medicare payments for mechanical ventilation to determine whether the DRG assignments and resultant payments were appropriate. We will review selected Medicare payments to determine whether patients received fewer than 96 hours of mechanical ventilation. Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. CMS requires that claims be completed accurately to be processed correctly and promptly. For certain DRG payments to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation.”

As you can see this is certainly not a new issue and hospitals need to remain vigilant in their efforts to correctly code ventilator hours.