Clinical or Medical Coding takes place across all settings in healthcare. Here in the United States, our healthcare system (industry) is extremely dependent upon the coding process and the selected codes for compliant billing and reimbursement. Those individuals in a management role must exude leadership, partnered with compliance in order to achieve the level of...
Pneumonia Clinical Indicators, Querying and Coding
A diagnosis of “Pneumonia” in the hospital inpatient setting has seen compliance reviews and Office of Inspector General (OIG) audits dating back to the early 1990s. Now hospitals (facilities) are seeing payer denials for this diagnosis, whether as a Principal diagnosis or as a Secondary (Additional) diagnosis. Keeping on top of healthcare claim denials can be daunting....
Query Compliance...Time to Confirm This!
Within Clinical Documentation Integrity (CDI) and clinical Coding we have verbal, written and electronic documentation clarifications or querying. A key component of the clinical documentation query is achieving and maintaining compliance. Having a written policy and procedure in place along with a formal quality review process for querying is thus essential and a must. ...
OIG: Annual Medicaid Fraud Control Unit Report
The Office of Inspector General (OIG) released in mid-March 2022 their annual report and statistics for 53 Medicare Fraud Control Units across the country. Significant investigative work and recoveries were obtained in 2021 totaling $1.7 billion recovered and 1,105 convictions. The 2021 annual Office of Inspector General (OIG) Medicaid Fraud Control Units (MFCUs) report...
OIG Releases “Medicare Advantage Compliance Audit of Specific Diagnosis Codes”
The Office of Inspector General released in January 2022 an audit report on Medical Advantage for Healthfirst Health Plan, Inc. The identified errors were related to some specific diagnosis codes and Hierarchical Condition Categories (HCCs). Another Medicare Advantage Audit Report from the OIG! This particular audit report by the Health and Human Services (HHS) Office of...
The OIG Focus on Clinical Coding
The last 12-18 months has brought the healthcare industry many audit reports from the Office of Inspective General (OIG). These reports are always an important part of every Compliance Program and the related audit and educational activities. Certainly, for Health Information Management (HIM), the OIG audit reports can provide a lens into issues, vulnerabilities, and...
2022 OIG Work Plan: Balancing a focus on overall compliance and the public health emergency
What another crazy year, huh?! In 2021, the OIG continued to publish its work plan with monthly updates including OIG audits and evaluations for the fiscal year and beyond. Although the COVID-19 pandemic continues on, healthcare operations and government oversight entities such as the OIG continue their work. As of the end of November 2021, the OIG had published 12 new...
The OIG Workplan and Building Your Own Coding Compliance Program
Each year the Office of Inspector General (OIG) publishes their annual work plan for healthcare, which is a highly anticipated publication. The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year. In addition, the OIG updates their workplan on a monthly basis, so their areas of...
