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Big Brother is Watching You!

COVID and the OIG

As you are aware the CARES Act of 2020 provides for an additional 20% above the billed DRG for treating a patient with a COVID diagnosis on or after January 27, 2020 until the end of the public health emergency (PHE).  Initially this was confirmed simply by the attestation of the condition but as of September 1, 2020 the positive test had to be included as part of the medical record and had to have been performed within 14 days of the hospital admission.  The OIG is now investigating to confirm compliance and it won’t be long before they are recouping money and applying penalties.  Hospitals are not the only entities being investigated.  Physicians who received money from the Provider Relief Fund, which was also created by the CARES Act, are required to not balance bill any patient seen with presumptive or actual COVID beyond what they would pay if seeing an in-network physician.  Although HHS broadly views every patient as a possible case of COVID, for this rule a presumptive case is where the medical record supports a diagnosis of COVID even if the patient does not have a positive test in the medical record.


Documentation and the OIG

MA plans have long been the subject of OIG audits for several reasons.  It is estimated that nearly 28 million people are enrolled in these plans representing 44% of those eligible for Medicare.  MA plans cost more per beneficiary than traditional Medicare and although some of this is related to some of the extra benefits they receive, much is related to more comprehensive coding of diagnoses in the MA patients.  In 2019, the risk scores of MA patients increased over 9% compared to the traditional Medicare patient.  Health and Human Services Department has found multiple instances of improper reporting of risk associated diagnoses including the use of health risk assessments and chart reviews to report diagnoses not associated with face-to-face visits and not meeting MEAT requirements.  To meet MEAT requirements one of the following must be documented.  The examples given are not all inclusive.

M: Monitor – symptoms, order tests, reference test results

E: Evaluation – medication effectiveness, physical exam findings

A:  Assess/Address – counseling, discuss or review records

T: Treat – refer to specialist, prescribe or continue medication


These diagnoses are being looked at by the OIG and we need to be sure they are well supported in the medical record.


Acute stroke–this should almost never be documented in an office encounter even if in follow-up of a recent hospitalization for acute stroke.  The residual effects of the stroke should be documented.  In the hospital, if a patient comes in for abnormal neurologic findings and a stroke was considered as a possibility but subsequently ruled out, it should not be coded.

Acute MI–this can be documented in an office encounter if it occurred within the last 28 days.  An old MI does not risk adjust.  A recent OIG review found chest pain incorrectly being called a MI when it was unstable angina which is a different risk adjuster.

Other diagnoses such as vascular claudication, pulmonary emboli and major depressive disorders are being looked at carefully and need to be clearly documented and need to meet the MEAT criteria to stand up to an OIG audit.

You need to be aware of these activities and others to avoid the wrath of the OIG.  Be sure you understand all the requirements of the Provider Relief Fund monies and comply with them.  Remember clear documentation and meeting MEAT for each diagnosis submitted on an ambulatory claim is your best protection against an audit.

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