Selected Topics from the 2015 OIG Work Plan: Inpatient Claims for Mechanical Ventilation

Selected Topics from the 2015 OIG Work Plan: Inpatient Claims for Mechanical Ventilation


by Christopher Richards, RHIA, CCS

This series of posts will highlight potential provider vulnerabilities with respect to the OIG 2015 work plan. Our sister company, Barry Libman Inc., is available to assist you with any areas where you feel you might have potential exposure. Certainly, everyone is in full agreement that a good compliance plan strives to identify concerns before the OIG does.


Hospitals—Billing and Payments – Inpatient claims for mechanical ventilation

“We will review Medicare payments for inpatient hospital claims with certain Medicare Severity Diagnosis Related Group (MS-DRG) assignments that require mechanical ventilation to determine whether hospitals’ DRG assignments and resultant Medicare payments were appropriate. Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. Claims must be completed accurately to be processed correctly and promptly.

“For certain DRGs to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation. Our review will include claims for beneficiaries who received over 96 hours of mechanical ventilation.  Previous OIG reviews identified improper payments made because hospitals inappropriately billed for beneficiaries who did not receive 96 or more hours of mechanical ventilation.”


96 hours of mechanical ventilation is necessary in order to use ICD-9-CM procedure code 96.72 (Continuous invasive mechanical ventilation for 96 consecutive hours or more).  Otherwise, procedure code 96.71 (Continuous invasive mechanical ventilation for less than 96 consecutive hours) should be used.

96 hours is the rule and 96 hours IS NOT the same as 4 days. To be compliant with this technical assessment, there must be clear documentation of the time that mechanical ventilation was initiated and include clear documentation that the patient remains on continuous invasive mechanical ventilation as of the 96th hour.

Any nonspecific documentation that a patient was on mechanical ventilation for four days without a clear start and stop time is likely to come under scrutiny. The OIG is counting hours.  You should be counting hours as well!  This issue applies to both short term acute care and long term acute care hospitals.

Coders are advised to monitor AHA Coding Clinic for evolving guidance.

About the Author

Chris Richards, RHIA, CCS
Chris joined Barry Libman Inc. as a Senior Associate in 2014 after 27 years with Masspro, the Massachusetts Quality Improvement Organization (QIO). Chris’s areas of expertise include health information administration, case management, quality improvement, hospital payment oversight, and documentation education initiatives. He has a comprehensive understanding of the Federal Medicare program rules and regulations, as well as extensive experience ensuring that clinical coding and DRG assignment result in accurate provider reimbursement. A graduate of Hobart College, he received a postgraduate Bachelor of Science in Health Information Administration from Northeastern University.

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