Purpose

To determine whether Medicaid overpayments were made to hospitals for mechanical ventilation services reported on APR-DRG (All Patient Refined Diagnosis Related Groups) inpatient claims. The audit covered the period from January 1, 2014 through December 31, 2018.

Background

Mechanical ventilation is the use of a device to inflate and deflate a patient’s lungs. Mechanical ventilation provides the force needed to deliver air to the lungs in a patient whose ability to breathe is diminished or lost. Hospitals use International Classification of Diseases (ICD) procedure codes on their claims to report mechanical ventilation services. When hospitals use a specific ICD procedure code to report a patient received 96 consecutive hours or more (i.e., four days or more) of mechanical ventilation, it may cause Medicaid’s payment to the hospital to increase. For the period of January 1, 2014 through December 31, 2018, Medicaid paid over $522 million to hospitals for 4,874 inpatient APR-DRG claims that included an ICD procedure code for 96 consecutive hours or more of mechanical ventilation services.

Key Finding

We identified $975,795 in overpayments on 32 inpatient claims that reported 96 consecutive hours or more of mechanical ventilation services. We found claims processing control weaknesses that prevent eMedNY from identifying claims where 96 consecutive hours or more of mechanical ventilation services was not possible.

Key Recommendations

• Review the overpayments we identified and make recoveries, as appropriate.
• Formally remind hospitals to use the procedure code that represents the duration of time the patient received mechanical ventilation services.
• Establish payment controls that validate the duration of mechanical ventilation services that hospitals claim.