OIG uncovers upcoding for stroke patients

A small number of hospitals, just 35 out of 4,883, had abnormally high DRG 014 discharges compared to national figures, according to a report just released by the Health and Human Services (HHS) Office of Inspector General (OIG). The OIG examined the proportion of DRG 014 discharges to total discharges in 1996 and the increase in the proportion of DRG 014 discharges to total discharges between 1993 and 1996.

The investigation showed that 4% of DRG 014 discharges sampled should have been coded to a lower-weighted DRG, according to the OIG. The Health Care Financing Administration (HCFA) pegged the overpayments at $11.9 million, or $1,716 a head.

In 1996, Medicare reimbursed hospitals almost $1.9 billion for DRG 014, a code used for stroke patients that can trigger a higher Medicare reimbursement than other codes where patients may exhibit similar symptoms. Among those 35 hospitals, DRG 014 discharges increased 73% (from 2,281 in 1993 to 3,941 in 1996), while DRG 014 discharges increased only 6% nationwide (from 360,354 in 1993 to 382,130 in 1996). Likewise, the proportion of DRG 014 discharges to all discharges for the 35 hospitals jumped 57% from between 1993 and 1996, while the national proportion increased only 1% during that time.

The OIG referred the 35 hospitals to its Office of Investigations. The report is the latest example of collaboration between HCFA and the OIG to perform routine monitoring and analysis of hospital billing and clinical data to uncover patterns of upcoding.