A hospital compliance auditor noticed during a routine audit that an unusually high number of pressure ulcers submitted on claims over the last six months were coded as state 3 or 4. A deeper analysis of the medical records revealed that an upgrade in the computer-assisted coding software had resulted in a glitch whereby the system was automatically assigning the codes for either a stage 3 or 4 pressure ulcer regardless of the stage identified in the clinical documentation. While the coders were supposed to review auto-assigned codes, they had missed the errors in the pressure ulcer codes. Since a stage 3 or 4 pressure ulcer is a major complication/comorbidity in the Medicare MS-DRG system, the coding error had led to inappropriate higher-paying MS-DRGs in some cases.
1)What should the auditor do?
2)What should be the next step to confirm whether incorrect does were submitted and resulted in overpayment?
3)If overpayment did occur, should the hospital just keep quiet about it and assume that other errors likely resulted in underpayments, so the overpayments and underpayments would probably balance each other out? If not, what actions should be taken?
4)Failure to report over-payments may result in liability under what federal statute(s) and / or law(s)?
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