Avoiding the OIG with Correct Coding

On March 13, 2020, the COVID-19 pandemic was declared a national emergency in the United States, forcing hospitals and health systems to adapt coding and billing policies according to rapidly changing rules and regulations. Health information management (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 US Department of Health and Human Services’ Office of Inspector General (OIG) is always at the forefront of HIM concerns. However, there are sound strategies for meeting coding, billing, and documentation requirements and avoiding the sting of an OIG audit.

Evolving Risks and Concerns

Historically, the OIG has targeted areas with high financial impact, which heightens the possibility that they will scrutinize coding and reporting of COVID-19 cases. In the near future, the OIG will likely add COVID-19 DRGs and lab billing for COVID-19 to their scope of work and conduct rigorous reviews of COVID-19 cases to check for appropriate coding, reporting, and payment.

Since the COVID-19 outbreak, changes have come quickly and frequently from the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), and the American Hospital Association (AHA) with updates regarding coding and reporting. As facilities receive new information, it takes time to disseminate it to the staff and assimilate the new guidance 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-19 as principal diagnosis. Early case reviews and audits have indicated confusion around reporting COVID-19 as a principal diagnosis. The fact that an individual tested positive for COVID-19 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-19,” “false negatives,” and “presumed COVID-19.” Assigning the principal diagnosis is one of the most challenging tasks for coders, and the novelty of coding the COVID-19 cases only exacerbated the issue.

Complications and syndromes. There is ongoing confusion about coding and reporting syndromes and lingering complications from COVID-19. 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-19 and sepsis sequencing. Coding Clinic guidance for sequencing COVID-19 versus sepsis was being interpreted differently by many users. Incorrect sequencing—COVID-19 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.

Strategies to Promote Proper Coding, Compliance, and Reimbursement

 Most of all, coders need consistent clarification and timely dissemination of the latest information. A process for communicating that information may have been overlooked while much of the coding workforce rapidly moved to a remote setting as the pandemic erupted. Support and reinforcement includes the following strategies:

• Audit a sample of cases to find errors and redirect efforts to ensure proper coding. Consider an outside auditor to identify and address issues proactively.
• Update guidelines in your coding compliance program to ensure consistent reporting and data integrity. Be sure to share the information as soon as it is disseminated.
• Conduct team meetings to ensure everyone is up to date and interpreting the guidelines in the same manner. Discuss common issues, share solutions, and address areas of confusion.
• Provide education on specific topics, such as the coding of sequela and manifestations of COVID-19:
  • Acute respiratory distress syndrome (ARDS)
  • Kawasaki disease
  • Pediatric multi-system inflammatory syndrome (PMSIS)
  • Cytokine release syndrome (CRS)

Ongoing education is more important than ever. Coders need an understanding of both disease processes and new guidelines to ensure accurate coding, reporting, and reimbursement. Starting now, take a look back and assess your vulnerability to the OIG and all payers. The results of reviews can help provide feedback and education to support accurate reporting and potentially correct improper reporting and payments that were made. A proactive approach will promote the best possible clinical and financial outcomes for your organization.

Laudine Markovchick (Laudine.Markovchick@pena4.com) is a coding professional with over 30 years of experience in the HIM field. She is currently the director of coding, data quality, and education with Pena4.