OIG and Correct Coding

Evolving Risks and Concerns

HIM departments face evolving risks regarding compliance with new coding, billing, and documentation requirements related to the pandemic. The threat of audits and reviews by the Office of Inspector General (OIG) is always at the forefront of HIM concerns. 

Historically, the OIG has targeted areas with high financial impact, which heightens the possibility that they will scrutinize coding and reporting of COVID cases. In the near future, the OIG will likely add COVID DRGs and lab billing for COVID to their scope of work and conduct rigorous reviews of COVID cases to check for appropriate coding, reporting, and payment.

Since the COVID outbreak, changes have come quickly and frequently from the CDC, CMS, and AHA with updates regarding coding and reporting. As facilities receive new information, it takes time to disseminate to staff and assimilate into the established workflow and guidelines. During the pandemic, management and oversight may be less stringent due to unprecedented demands on all hospital staff.

Hospitals that are not able to keep abreast of updates and changes in a timely manner may be at a higher risk for errors when it comes to accurate coding, billing, and documentation.

As things begin to settle to a point that facilities can take time to review cases and identify potential areas at risk, here are three focus points to review:

COVID as principal diagnosis.

Early case reviews and audits have indicated confusion around reporting COVID as a principal diagnosis. The fact that an individual tested positive for COVID on admission doesn’t mean that it was the principal diagnosis—meaning the reason for admission to the hospital. In addition, there are specific guidelines with regard to “possible or probable COVID,” “false negatives,” and “presumed COVID.” Assigning the principal diagnosis is one of the most challenging tasks for coders, and the novelty of coding the COVID cases only exacerbated the issue.

Complications and syndromes.

There is ongoing confusion about coding and reporting syndromes and lingering complications from COVID. Guidance in this area continues to flow as more comorbidities and sequela are identified. In the meantime, we should report all signs and symptoms for any comorbidities/sequela in the absence of a specific code.

COVID and sepsis sequencing.

Coding Clinic guidance for sequencing COVID versus sepsis was being interpreted differently by many users. Incorrect sequencing—COVID as primary diagnosis when sepsis was present on admission—can result in DRG errors and financial impact. Facilities can expect that the OIG will focus on these errors in efforts to recoup overpayment.

Ongoing audits are more important than ever before. We have coding auditors and managers ready to assist.