The Office of Inspector General (OIG) “Work Plan” is a roadmap to many compliance focused areas across healthcare. In addition, the Work Plan can serve as an audit plan for many healthcare settings identifying where compliance risks of overpayments are from federally funded programs. With the focus on specific Health and Human Services (HHS) programs, the OIG Work Plan is helping to protect the funds used for the Medicare and Medicaid healthcare services and beneficiaries. The OIG Work Plan is a valuable tool and can be accessed at: https://oig.hhs.gov/reports-and-publications/workplan/

A November update to the Work Plan indicates that the diagnosis of “Malnutrition” is being focused on again. The title of this addition is “Medicaid Inpatient Hospital Claims With Severe Malnutrition” and is being handled by the Office of Audit Services. The OIG describes this work in the following manner:

Malnutrition can result from treatment of another condition, inadequate treatment or neglect, or general deterioration of a patient’s health. Hospitals are allowed to bill for treatment of malnutrition on the basis of the severity of the condition (mild, moderate, or severe) and whether it affects patient care. Severe malnutrition is classified as a major complication or comorbidity (MCC). Adding an MCC to a claim can result in an increased payment by causing the claim to be coded in a higher diagnosis-related group. We will conduct statewide reviews to determine whether hospitals complied with Medicaid billing requirements when assigning severe malnutrition diagnosis codes to inpatient hospital claims.

Over the past 7+ years we have seen the OIG release several audit reports regarding the diagnosis coding of “Malnutrition”. With many ICD-9-CM and ICD-10-CM diagnosis codes that represent different types and stages of Malnutrition there can be issue of accuracy as well as problematic clinical documentation. Here is short list of OIG work regarding “Malnutrition”.

• HOSPITALS Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claim: 07-13-2020, A-03-17-00010
• UNIVERISTY of Wisconsin Hospitals and Clinics Authority Incorrectly Billed Medicare Inpatient Claims With Severe Malnutrition Audit: 06-01-2018, A-03-17-00005
• CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor – 11-2017, A-03-14-00010
• REX Hospital Incorrectly Billed Medicare Inpatient Claims with Kwashiorkor: 02-2015, A-03-14-00008
• METHODIST Hospital Incorrectly Billed Medicare Inpatient Claims with Kwashiorkor: 01-2015, A-03-14-00005
• BAPTIST Medical Center Incorrectly Billed Medicare Inpatient Claims with Kwashiorkor: 12-2014, A-03-14-00007
• OVERLOOK Medical Center Incorrectly Billed Medicare Inpatient Claims with Kwashiorkor, 10-2014, A-03-14-00003
• MOTHER FRANCES Hospital Incorrectly Billed Medicare Inpatient Claims with Kwashiorkor: 09-2014, A-03-14-00006
• PALMETTO Health Baptist Hospital Incorrectly Billed Medicare Inpatient Claims with Kwashiorkor: 02-2014, A-03-13-00029

Many of these audits found that the severe malnutrition diagnosis codes assigned/used should have been for other forms of malnutrition or no malnutrition ICD-9-CM/ICD-10-CM diagnosis code at all. To complicate matters, we have seen and read about the American Society of Parenteral and Enteral Nutrition (ASPEN) clinical criteria for malnutrition. Although a highly regarded professional organization there are gaps between their definitions of the types and stages of Malnutrition and those of the coding classification system. Auditing and providing education are key for Clinical Documentation Integrity and Coding Professionals as well as providers. Plan now for an audit of hospital encounters with a diagnosis code from the malnutrition category.

Telehealth services have really expanded since the COVID-19 Pandemic hit. The OIG Work Plan now lists “Telehealth Services in Select Federal Health Care Programs” as part of their work for the Office of Evaluation and Inspections. Per the OIG Work Plan the following is the description of this work:

Telehealth is playing an important role during the public health emergency (PHE), and CMS is exploring how telehealth services can be expanded beyond the PHE to provide care for Medicare beneficiaries. Because of telehealth’s changing role, we will conduct a series of audits of Medicare Part B telehealth services in two phases. Phase one audits will focus on making an early assessment of whether services such as evaluation and management, opioid use disorder, end-stage renal disease, and psychotherapy (Work Plan number W-00-21-35801) meet Medicare requirements. Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.

From what we understand, these audits will review remote patient monitoring, virtual check-ins, and e-visits. Back in 2018, you may recall that the OIG issued a report regarding a 31-percent error rate of claims for telehealth. This report of course was prior to the explosion of telemedicine in 2020 due to the COVID-19 Public Health Emergency.

The OIG and I hope your own practice and/or facility wants to ensure that the benefits of telehealth are not compromised by fraud, abuse, or misuse. Thus, at this time you should conduct a “compliance check-up” of telehealth services by evaluating their services, operations, training, compliance program, coding, and billing practices to ensure compliance with federal health care program requirements. This includes performing both internal and external auditing. You can access the OIG Telehealth Service work plan at: Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency (hhs.gov)

Remember that the OIG’s work planning process is dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available.