Following all the rules can be complicated. And sadly, following all the rules is not optional. Mary Inman frequently reports here on the consequences of not following the rules, and the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) releases a daily email with all the new Medicare criminals, delineating their malfeasance.
But keeping up really is hard. The Centers for Medicare & Medicaid Services (CMS) releases new rules on a regular basis, and then they release transmittals explaining the application of the new rules. They then issue new guidance documents explaining the transmittals. They publish MLN Matters on a regular basis, with education on common topics for which they think new education is warranted. And the Medicare Administrative Contractors (MACs) release their own education. Who has the time to read all that?
But sometimes, things go wrong. Last week the CMS weekly MLN Connects Newsletter had an article in the compliance section that caught my attention. It was titled “Mechanical Ventilation: Bill Correctly for Inpatient Claims.” For those who are unaware, for several Diagnosis-Related Groups (DRGs), including sepsis, if the patient is mechanically ventilated for more than 96 hours, the DRG changes to a much higher-valued DRG, and hence a significantly higher payment (and with that, the risk of overpayment).
At first glance, this article reminded me that we still have not seen any sign of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) making its long-awaited return – and mechanical ventilation over 96 hours was one of the measures. How long can it take CMS to revamp it? Heck, we have been waiting so long that 98-year-old Mel Brooks even has had time to plan and announce a sequel to Spaceballs.
So, I eagerly started reading the article, and there was a link to the OIG report from last August. That report found a not-so-impressive 6.8-percent error rate in their audit. And as they always do, the OIG recommended that CMS educate providers on properly counting ventilator hours. I will admit, though, that this really should not be that hard; the coder looks for the time and date on the note that was written when the patient was intubated and the note when the patient was extubated. But apparently, some are not doing it right – or perhaps they are counting the hours correctly, but are using the wrong ICD-10-PCS code to the claim.
Nonetheless, I was eager to see what new education CMS was providing, so I read on. And the next section said “On your claims for mechanical ventilation, use the right procedure and diagnosis codes, including codes for the correct number of hours. Review the ventilators provider compliance tip for more information.” And so I opened that link.
Lo and behold, what did I find but links to instructions and the national coverage determination for proper documentation, coding, and billing for patients who are on home ventilators, which are considered Durable Medical Equipment (DME). Not one word about mechanical ventilation in the hospital.
What happened here? Well, I discussed this with a prominent compliance expert, and she wondered if perhaps DOGE installed artificial intelligence to replace humans to write the MLN Connects, and the computer did not understand the difference between in-hospital mechanical ventilation and home ventilators. It certainly seems that a human would have noticed that the educational material had nothing to do with the topic.
I did report this to CMS, and I am sure they will correct it, but will it happen again with other topics? You know I’ll be watching.
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