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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 noncompliance with clinical coding. Now before I go any further let’s all acknowledge that we have to consider the clinical “ documentation” that may be the direct source of clinical coding issues. As we are about to end our second year with a Public Health Emergency (PME) due to the COVID-19 pandemic, it’s good to look back and reflect upon the OIG focus on Clinical Coding.

The mission of the Office of Inspector General (OIG), as mandated and amended by Public Law 95-452, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections. The following are the areas in which the OIG work is conducted:

  • Office of Audit Services
  • Office of Evaluation and Inspections
  • Office of Investigations
  • Office of Counsel to the Inspector General

Another key component to the above mission is the OIG Annual Work Plan. The “Work Plan,” which is regularly updated with topics or focused issues is a major resource with Compliance, Revenue Cycle and HIM. Go to the OIG HHS website for more information:

We saw that CPT™ coding and documentation were being focused on within the OIG work titled, Use of Medicare Telehealth Services During the COVID-19 Pandemic”; this area of focus was announced in July of 2020. With the increased use of “Telehealth” it’s important to have ongoing auditing and monitoring of this service line which could be at the physician office or in the hospital outpatient setting.

The OIG report titled: Inadequate Edits and Oversight Caused Medicare To Overpay More Than $267 Million for Hospital Inpatient Claims With Post-Acute-Care Transfers to Home Health Services” was published 8-05-2020, number A-04-18-04067 . Although not specific to ICD-10-CM/PCS coding, the acute care hospital coding professional often selects and/or assigns the discharge status code (discharge disposition) so this is a subject to audit and educate on.

In June 2020, the OIG announced they will audit the “CARES Act Provider Relief Funds—Distribution of $50 Billion to Health Care Providers”. In September, the OIG audit Medicare payments made to hospitals for COVID-19 discharges that qualified for a 20 percent add-on payment under the Coronavirus Aid, Relief, and Economic Security (CARES) Act. This OIG work is titled, “Audit of Medicare Payments for Inpatient Discharges Billed by Hospitals for Beneficiaries Diagnosed With COVID-19”. This OIG issue does cite ICD-10-CM code(s) that every HIM coding professional should read about. The CMS MLN SE20015 was updated on September 11, 2020, New Waivers for Inpatient Prospective Payment System (IPPS) Hospitals, Long-Term Care Hospitals (LTCHs), and Inpatient Rehabilitation Facilities (IRFs) due to Provisions of the CARES Act, this MLN can be found at: SE20015 (

During 2021, the regular RMC blogs have provided information on many of the OIG audits and activities during the year. For Clinical Coding Professionals, these OIG Audit Reports serve as “red flags” of noncompliance and provide direction on areas of weakness and those prone for errors. The February OIG report titled, “Trend Toward More Expensive Inpatient Hospital Stays in Medicare Emerged Before COVID-19 and Warrants Further Scrutiny” was released. This report has brought attention to MS-DRGs and the documentation and clinical coding. MS-DRG 871 Septicemia or Severe Sepsis without MV 96 hours with MCC”, was discussed as a potential ICD-10-CM coding problem, thus auditing very closely this particular MS-DRG and the supporting clinical documentation is vital to conduct.

Early May 2021 the OIG report titled, “Medicare Hospital Provider Compliance Audit: Virtua Our Lady of Lourdes Hospital”, was released and targeted a variety of settings and issues:

  • IRF claims
  • inpatient claims billed with Comprehensive Error Rate Testing (CERT) high-error rate DRG codes
  • inpatient claims billed with high-severity- level DRG codes
  • inpatient mechanical ventilation claims
  • inpatient claims paid in excess of charges
  • outpatient claims paid in excess of $25,000
  • outpatient claims paid in excess of charges
  • outpatient bypass modifier claims
  • outpatient surgeries billed with units greater than one
  • outpatient skilled nursing facility (SNF) consolidated billing.

In September, the OIG released a report titled: “Some Medicare Advantage Companies Leveraged Chart Reviews and Health Risk Assessments To Disproportionately Drive Payments” (OEI-03-17-00474) which came from the OIG department of “Evaluations and Inspections”. This particular OIG report can be accessed via the following link: In an October 2021 OIG audit release, came the report titled, “Medicare Advantage Compliance Audit of Specific Diagnosis Codes that Coventry Health Care of Missouri, Inc. Submitted to CMS”. In this particular OIG Audit focused upon Hierarchical Condition Categories (HCCs) from ICD-10-CM codes in the following categories:

  • Acute stroke
  • Acute heart attack
  • Embolism
  • Vascular claudication
  • Major depressive disorder

Potential misdiagnosis (Defined by the OIG as when a patient received multiple diagnoses for a condition but received only one—possibly mis-keyed—diagnosis for an unrelated condition)

Whether it’s a lack of clinical documentation, incorrect CPT codes, ICD-10-CM/PCS codes, or a combination of documentation and coding, there is lots that the OIG is looking at in the clinical coding arena. Please note that I’ve not included all of the OIG audit reports that were or maybe were related to clinical coding, but you get the message loud and strong for the above.

So, Yes, these OIG audit reports are extremely valuable and can aide in focusing on the clinical coding areas as well as documentation with vulnerabilities. Discuss the OIG reports with your Coding staff, Auditing team, Compliance and Revenue Cycle leadership. Coding education should be continuously and not just twice a year associated with the code updates. It takes more than education twice a year to increase ones knowledge about clinical coding. Healthcare regulatory scrutiny is clear and present; thus, the time is now to be proactive, so drive and strive for accuracy. Ensure that errors are corrected and that rebilling or refunding is completed as well. Best of luck with your auditing and education and let’s make it a point to be attentive to the 2022 OIG healthcare audit reports!

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This program has been approved for continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.