MECHANICAL VENTILATION IS UNDER REPORTED ON CLAIMS: A COMPARISON OF CHARGE DESCRIPTION MASTER DATA TO CLAIMS DATA
Author(s)
Virginia Gleason, BS, MPH, JD1, Edward J. Burleigh, MBA2.
1Principle Clinical Expert, FinThrive, Ronan, MT, USA, 2FinThrive, Newtown, GA, USA.
1Principle Clinical Expert, FinThrive, Ronan, MT, USA, 2FinThrive, Newtown, GA, USA.
OBJECTIVES: An OIG audit for 2009-2011 discovered an error rate greater than 95% in mechanical ventilation billing to Medicare.A repeat audit for 2015-2021 was published August 2024 and demonstrated nearly the exact opposite result.The published 2024 study showed a 93% compliance rate; resulting in an error rate of only 7%.This research aims to explore if hospitals are under reporting mechanical ventilation on claims.
METHODS: Broadly speaking,the Charge Description Master(CDM) includes charge data regarding procedures and services provided by hospitals.This study compares CDM data to UB-04 claims data to determine if CDM is a better data source for capturing the use of Mechanical Ventilation in hospitalized patients.Capturing charges as services are provided is integrated with the EHR to minimize the chance of missed charges. Medical coding translates the details from the charge capture and medical record documentation into standardized codes used across the healthcare industry.Coding rules turn medical records into language payers and billing systems understand.This language is based on what can be billed and reimbursed not the full list of services provided.Utilizing 837 electronic claims data for CY 2019-2025 FinThrive identified the number of patients with principle diagnosis Guillain-Barre Syndrome(G61.0) for whom mechanical ventilation was coded and billed.Utilizing a unique patient key,the same patients were identified in the CDM dataset.
RESULTS: Mechanical ventilation services were identified in claims data for 1,338 unique patients and 1,463 unique encounters during CYs 2019 - 2025. The CDM data showed 2,682 unique patients and 2,919 unique encounters mechanical ventilation services were provided.
CONCLUSIONS: Mechanical ventilation is underreported in claims data for patients with Guillain-Barre Syndrome.This study supports the need to expand the investigation to all diagnosis codes and hospital departments which is currently underway.The current data supports that CDM data is a better source to identify patients requiring mechanical ventilation as part of hospital services.
METHODS: Broadly speaking,the Charge Description Master(CDM) includes charge data regarding procedures and services provided by hospitals.This study compares CDM data to UB-04 claims data to determine if CDM is a better data source for capturing the use of Mechanical Ventilation in hospitalized patients.Capturing charges as services are provided is integrated with the EHR to minimize the chance of missed charges. Medical coding translates the details from the charge capture and medical record documentation into standardized codes used across the healthcare industry.Coding rules turn medical records into language payers and billing systems understand.This language is based on what can be billed and reimbursed not the full list of services provided.Utilizing 837 electronic claims data for CY 2019-2025 FinThrive identified the number of patients with principle diagnosis Guillain-Barre Syndrome(G61.0) for whom mechanical ventilation was coded and billed.Utilizing a unique patient key,the same patients were identified in the CDM dataset.
RESULTS: Mechanical ventilation services were identified in claims data for 1,338 unique patients and 1,463 unique encounters during CYs 2019 - 2025. The CDM data showed 2,682 unique patients and 2,919 unique encounters mechanical ventilation services were provided.
CONCLUSIONS: Mechanical ventilation is underreported in claims data for patients with Guillain-Barre Syndrome.This study supports the need to expand the investigation to all diagnosis codes and hospital departments which is currently underway.The current data supports that CDM data is a better source to identify patients requiring mechanical ventilation as part of hospital services.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
RWD36
Topic
Real World Data & Information Systems
Disease
No Additional Disease & Conditions/Specialized Treatment Areas