Auditors have been eyeing COVID-19 diagnoses and sequencing, but related MS-DRG risks are now under the microscope, with the HHS Office of Inspector General (OIG) adding inpatient claims with mechanical ventilation to its Work Plan.^[1] Maybe that’s not a shocker, considering the fact that the use of mechanical ventilation has skyrocketed because of the pandemic, and MS-DRG reimbursement jumps when patients with respiratory diagnoses or sepsis are on ventilators for 96 hours or more, experts say. OIG will review claims to determine whether hospitals billed the higher-paying MS-DRGs for patients who didn’t cross the 96-hour threshold, a calculation that may be easier said than done for hospitals.

“COVID has contributed to the uptick in the utilization of vents, especially in the beginning of the pandemic,” said Maggie Naawu, a specialist master at Deloitte Advisory. “Since there are different levels of payment for vents based on the duration and whether or not sepsis is a factor, the OIG is probably looking to recoup some money on the accuracy of vent hours coded.”

Beneficiaries must be on the vent for 96 hours or more consecutively for MS-DRGs 207 (respiratory system diagnosis with ventilator support 96+ hours) and 870 (septicemia or severe sepsis with mechanical ventilation 96+ hours). If they’re ventilated fewer than 96 hours, the DRGs are 208 and 871, which pay considerably less. For example, the MS-DRG for a sepsis patient who is on mechanical ventilation for 96 hours or more may be triple that of a patient on a vent for 95 hours, said Kristen Shattuck, a specialist leader with Deloitte & Touche. “Coders have to make sure they look at those times” and do the math down to the hour or the minute and capture that correctly.