OIG Report: Data brief with concerns for potential upcoding

by Tiffany Ferguson, LMSW, ACM
Published on Mar 01, 2021

The Office of Inspector General released a data brief looking at hospital admissions from FY 2014-FY 2019.  Their findings recommended CMS to further evaluate a major concern of possible upcoding, specifically for CMS to evaluate a targeted review of MS-DRGs and stays that billed at the highest severity with a lower-than-expected length of stay.  Thankfully, CMS has declined an interest to further investigate or target specific hospitals at this time.  But that does not mean that they will not come knocking in the future. 

The OIG found a 20% increase in the number of stays for the highest severity level, nearly accounting for half of all Medicare inpatient spending.  At the same time, the average length of stay decreased for these high severity stays. 

Nearly one-third of these high severity stays, lasted a ‘particularly short amount of time’ and more than half only had one diagnosis qualifying them for payment at that level. 

To ensure your hospital is compliant, review of your PEPPER Report and discuss at your upcoming UR Committee potential risks.  Specifically, self-audit to ensure compliance for any records that are:

  • Coded at the highest severity level with a short length of stay.
  • Coded at the highest severity level with only one major complication.