August 25, 2025

Top Questions from the Key Insights From the OIG Work Plan Webinar

Looking for more information about Key Insights From the OIG Work Plan? BESLER’s Senior Manager of Revenue Integrity Kristen Eglintine answers your questions from the recent webinar.

To watch Kristen and Mary’s Key Insights From the OIG Work Plan Webinar, click HERE.

1. 1. 1. 1. Where can I find a list of the criteria that needs to be met? Sometimes I look this up, but the correct criteria list won’t come up not only for these codes/procedures but for other procedures as well?
        
        I’m not sure what topic you are asking about; however, I would recommend the ACDIS CDI Pocket Guide for clinical criteria for IP diagnoses. Lots of great information by topic are provided in this publication.
      2. In terms of right heart catheterizations, if the physician states that the biopsy is a distinct and separate procedure from the heart cath, will that be sufficient or do I need more documentation than that?
        
        A physician’s statement alone that the biopsy is a “distinct and separate procedure” from the right heart catheterization is not sufficient for billing both procedures separately. According to coding and compliance guidelines, you must have:
        
        1. Detailed documentation of medical necessity and rationale for performing both the right heart cath and the biopsy as separate procedures. This must go beyond just a physician’s attestation—it should clearly state: The clinical scenario justifying each procedure, why both were needed in the same encounter and distinct diagnoses or indications, when applicable.
        2. Procedure reports for each, describing the steps and findings.
      3. Are these procedures something the OIG is currently checking or something they will be looking at in 2026?
        
        Many topics from the OIG 2025 Work Plan are already actively under review or in progress. I would check their website for specific information as the OIG updates its work plan monthly and categorizes project status as “initiated,” “in development,” or “planned.” The “active” work plan items table shows which audits, evaluations, and inspections are already underway, not just planned for the future.
      4. Are providers informed of their lack of medical necessity or other documentation discrepancies when OIG identifies a claim that has been rejected?
        OIG typically does not directly inform providers of lack of medical necessity for individual rejected claims. Claim rejections based on lack of medical necessity are usually communicated by the payer (e.g., Medicare or Medicaid contractor, MAC, MCO), not directly by the OIG itself.
      5. How does OIG monitor Major Depressive disorder? Do they also look for unspecified depression codes?
        
        The OIG has a list of red flags that include a lack of supporting treatments or medications, and the use of a diagnosis where only a history of the condition should have been coded. See the question and answer below, too.
      6. What about Major Depression specifically does the OIG get red flags for? Lack of MEAT in documentation, if so, what documentation is needed to meet a requirement for MDD? Depression unspecified?
        
        For major depressive disorder (MDD) billed on outpatient (OP) claims, the OIG expects medical records to contain comprehensive documentation supporting the diagnosis and ongoing management. Specifically, the documentation should include:
        Patient History
        Symptom Assessment
        Episode & Severity
        Clinical Status
        Treatment Plan
        Ongoing Monitoring
        
        Key OIG Audit Triggers for MDD are:
        Diagnosis submitted with no associated antidepressant therapy or management.
        No evidence of clinical criteria or severity/detail to justify coding for MDD.
        Single occurrence of the diagnosis with no follow-up, therapy, or continued management in the medical record.
      7. One of our payers is citing the OIG as saying that sepsis is not an appropriate outpatient diagnosis and that all patients with sepsis should be inpatient. However, I cannot find the OIG report that states this. Have you seen or heard anything from the OIG about this?
        
        Some payers cite OIG as the reason for editing their internal claim policies, denying claims for acute stroke and sepsis billed in the outpatient setting, often referencing OIG audit findings about clinical appropriateness. These are payer-level decisions and not formal federal regulations or mandates. Some payer communications and commentary reiterate OIG’s stance that these diagnoses are “rarely, if ever, appropriate for outpatient claims,” typically requiring inpatient treatment, but they do not reference a specific OIG directive or published report mandating this approach.
      8. Why was it stated, that the Malnutrition issue is with Medicare and Medicaid accounts when the workplan states, “Medicaid” only? Has there been clarification that this Work Plan also involves Medicare claims as previously reviewed?
        
        I apologize, I misspoke. The current OIG workplan item titled “Medicaid Inpatient Hospital Claims With Severe Malnutrition” (announced for 2025) is focused specifically on Medicaid accounts and billing compliance for inpatient claims. The scope as stated in the Work Plan is indeed limited to Medicaid reviews for this round.
        
        However, even though the 2025 OIG workplan language currently states “Medicaid,” the underlying issue and audit focus are consistent with previous reviews of Medicare claims. There is ongoing clarification and concern that Medicare accounts may be reviewed again, so hospitals and providers should not assume the issue is limited solely to Medicaid billing. It is prudent to maintain compliance for both programs.