2010 ubo/ubu conference health budgets & financial policy 111 briefing: common coding pitfalls...

2010 UBO/UBU Conference

Health Budgets & Financial Policy

111

Briefing: Common CodingPitfalls Impacting MS-DRGs

Date: 24 March 2010

Time: 1300–1350

2010 UBO/UBU ConferenceTurning Knowledge Into Action

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Objectives

Foster greater understanding about MS-DRGs– Background– Weighted value (TRICARE)

Identify Common Coding Pitfalls Discuss Rescue Attempts Summation


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MS-DRGs Background

Military Health System (MHS) adopted the Medicare Severity-DRGs effective 1 October 2008 (FY09).

TRICARE/CHAMPUS DRG uses– MS-DRG logic– MS-DRG assignment for SIDR

DoD assigned weightshttp://www.tricare.mil/drgrates/

– TRICARE MS-DRG


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MS-DRGs Background (cont’d)

Evolution brought change and new terminology.– Increased number of DRGs– Revised CC listing– Created MCCs– Hospital-Acquired Conditions (HACs)– Present on Admission (POA) indicator

Under the MS-DRGs, the severity of a patient’s illness must be more accurately documented in order for the hospital to be reimbursed appropriately for the care provided.

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MS-DRG Terminology

MS-DRG: Medicare Severity-Based Diagnosis Related Groups Complexity: Differences in resource needs that are not

diagnosis-related – Heart assist devices– Organ transplants– Bone marrow transplants– Tracheostomy

CC: A secondary diagnosis determined to be a complication or co-morbidity in relationship to the principal diagnosis

MCC: A secondary diagnosis determined to be a complication or co-morbidity which exceeds the resource use of the standard CC


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DRGs vs. MS-DRGs

DRGs split – Age– With CC– Without CC

MS-DRGs split – Tiers– Presence or absence of CC– If present, is CC “major” (MCC) or not? – Could result in up to three tiers of payment

Absence of CC Presence of CC Presence of MCC

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MS-DRGs – Assignment to Severity Tiers

Severity and weight increase with each tier Severity tier depends on secondary diagnosis

MS-DRG Description Weight (FY10)291 Heart Failure and shock w/MCC 1.4872292 Heart Failure and shock w/CC 0.9164 293 Heart Failure and shock w/o CC/MCC 0.7176

If none of the secondary diagnoses codes are MCCs or CCs, the MS-DRG w/o CC/MCC is assigned.

MCCs take precedence over CCs.

Only one CC or MCC code is needed for assignment to a specific MS-DRG. BUT, DON’T STOP there!


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Initial Split: TRICARE MS-DRG in 2009

014 Intracranial Hemorrhage or Cerebral Infarction

1.3807

064 Intracranial Hemorrhage or Cerebral Infarction w/MCC

2.4223

065 Intracranial Hemorrhage or Cerebral Infarction w/CC

1.3422

066 Intracranial Hemorrhage or Cerebral Infarction w/o CC/MCC

1.0291

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FY09

Note: Comparison is FY08 DRG w/ FY09 MS-DRG.

FY08


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Initial Split: TRICARE MS-DRG (cont’d)

127 Heart Failure and Shock

1.0292

291 Heart Failure and Shock w/MCC

1.4248

292 Heart Failure and Shock w/CC

0.9638

293 Heart Failure and Shock w/o CC/MCC

0.6815

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NEW

Note: Comparison is FY08 DRG w/ FY09 MS-DRG.

FY08


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TRICARE MS-DRG 2008 / 2009 / 2010

078 PulmonaryEmbolism

1.1580

175 PulmonaryEmbolismw/ MCC

1.5659 1.3731

176 PulmonaryEmbolismw/o MCC

1.0013 0.9910

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NEW

Notice adjustment from FY09 to FY10

FY08 FY09 FY10


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TRICARE MS-DRG 2008 / 2009 / 2010

103 Heart Transplant or Implant of Heart Assist System

21.2217

001 Heart Transplant or Implant of Heart Assist System w/MCC

31.2385 23.1022

002 Heart Transplant or Implant of Heart Assist System w/o MCC

12.4056 15.8832

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NEW

Notice adjustment from FY09 to FY10

FY08 FY09 FY10


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How DRGs 079, 080, & 081 Changed

177 Respiratory infections and inflammations w/MCC

2.4099 2.3302

178 Respiratory infections and inflammations w/CC

1.7119 1.8230

179 Respiratory infections and inflammations w/o CC/MCC

1.1799 1.0813

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MS-DRGs

FY09

FY10


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Common Coding Pitfalls

Lack of Documentation Lack of Granularity (in data) Decrease in Case Mix Index (severity) Wrong POA Indicator Loss of Revenue


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Pitfall – Lack of Documentation

Scenario: Patient admitted with abdominal pain and melena. Repeat lab shows precipitous drop in Hct.

Discussion:– Melena (578.1 or 562.xx [GI tract, unsp/diverticulosis/

diverticulitis]) – could be CC/MCC

– No documentation re: precipitous drop in Hct– Is CC/MCC missing? – Could it be anemia?

Chronic blood loss (unspecified) – No CC or MCC Acute post-hemorrhagic anemia – CC

Diagnostic Findings– Lab and other ancillary tests– Biopsies

Only one CC or MCC needed …BUT, DON’T STOP there!


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Rescue

Fact: precipitous drop in Hct

Was there blood loss? Was there an impact due to blood loss? Was there treatment for possible blood loss? Is it associated w/the melena? Is drop in Hct indicative of another condition?

– Is it anemia? – Other blood dyscrasia?

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Rescue: Query the physician


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Pitfall – Documentation of Neonatal Codes

Scenarios: Physician uses both Transient Tachypnea of the

Newborn (TTN) and Respiratory Distress Syndrome (RDS) in the baby’s chart, AND

Physician does not clearly explain (at discharge) which is correct, OR

Continuous Positive Airway Pressure (CPAP) or high nasal cannula (HFNC) used for > 24 hours


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Neonatal Codes (cont’d)

“The American Hospital Association’s Coding Clinic from November-December 1986 initially separated RDS into type 1 (coded to 769) and type 2 or TTN (code 770.6). It further stated that the type 2 version was also referred to as mild and commented that recovery was generally made by the third day of life.

Confusion continued, however, and the first quarter 1989 issue of Coding Clinic added that the two conditions were mutually exclusive: The coder was allowed to apply only one of the diagnoses. The explanation continued that the tabular instructions with each code excluded the other, and RDS includes clinical symptoms of tachypnea. It further added that the milder diagnosis of TTN ‘by definition resolves within 6 to 24 hours of birth.’ …

Even physicians themselves have trouble reaching a consensus about when the problem constitutes RDS and when the symptoms are representative of the less severe diagnosis of TTN…If neither the payers nor the doctors can agree on what constitutes a valid RDS diagnosis, how are coders supposed to figure it out?”

Reference: “Dealing With Fussy Neonatal Codes” For the Record, October 13, 2008.

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Excerpt…


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Rescue

Discussion: If documentation in chart is TTN, there are no significant CXR findings, the

baby makes a speedy recovery, there was no O2 or face mask was used for a few hours only – TTN code is appropriate. OR,

If baby is preterm, CXR shows significant findings and requires Rx for resolution, gets CPAP or other mechanical ventilation for > 24 hrs, and documentation = hyaline membrane disease or RDS, the code 769 would be appropriate. BUT,

If discharge note shows mild RDS or hyaline membrane disease, or the physician uses both RDS & TTN in the note, or not in the note but in the same chart, and never clearly states which was correct …

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RESCUE: Query the provider• Do Not Guess• Risk and Reimbur$ement at stake• Coder not clinically qualified re: final diagnosis.


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Pitfall and Rescue

Pitfall: Not staying abreast of coding changes

Pitfall: Not establishing a working relationship with providers

Pitfall: Not optimizing reimbursement opportunities

New Major Complications and Comorbidities (MCC) for current fiscal year. 277.88 Tumor lysis syndrome 670.22 Puerperal sepsis (delivered w/postpartum complication) 670.24 Puerperal sepsis (postpartum condition/complication) 670.32 Puerperal septic thrombophlebitis (delivered w/postpartum complication) 670.34 Puerperal septic thrombophlebitis (postpartum condition/complication) 670.80 Other major puerperal infection (unspecified episode or N/A) 670.82 Other major puerperal infection (delivered w/postpartum complication) 670.84 Other major puerperal infection (postpartum condition/complication) 756.72 Omphalocele 756.73 Gastroschisis 768.73 Severe hypoxic-ischemic encephalopathy 779.32 Bilious vomiting in newborn

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Rescue: Read! Read! Read! Could the CC be a MCC? Capitalize on educational

opportunities!


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Pitfalls and Rescue

Pitfall: Inadequate Physician Documentation

Pitfall: Lack of Specificity

Pitfall: Lack of granularity● In general

● 4th and 5th level of the ICD-9-CM code

● Did you read through all pertinent documents when coding the record?

● Discharge Summary/Note● History/Physical (H/P) Examination● Operation/Pathology Report

● Did you look for “details” in the ancillary notes/reports?● Did you follow up on problems?

● Focused audits● Educating the providers

•

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Rescue: More Adjectives!


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Pitfall – Decrease in Case Mix Index (CMI)

Pitfall: Not knowing coding trends

Pitfall: Not knowing case mix

Pitfall: Not capturing appropriate level of severity

Pitfall: Not using appropriate secondary diagnoses

Pitfall: Not getting appropriate reimbur$ement

Pitfall: Not getting accurate record of patient care

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Rescue

Rescue:● Monitor coding pattern changes● Don’t ignore the “specifics” in the documentation (including

ancillary notes/reports)● Code all significant conditions (CC/MCC)/surgery● Results

● Increase in hospital resources for● Treatment of acute disease● Treatment of chronic diseases (advanced, exacerbated,

or associated with extensive disability)

● Accurate reimbursement

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A true picture of how sick your patients are…


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Rescue (cont’d)

Rescue:● Implement Clinical Documentation Improvement (CDI)

plan● Education (coders/providers)● All rescue plans activated…

● Accurate record of patient care● Appropriate reimbur$ement● Accurate CMI and severity● It’s your MTF’s report card!

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Rescue (cont’d)

Compute CMI for your MTF for specified time frame CMI = average cost weight for all discharges

Example:

- Total RWPs = 12,450

- 9,575 discharges

- CMI = (12,450/9575) = 1.3003 Many factors

– Classification system used– Statistical methodologies, etc.– +/- “outliers”

Baseline and Trend Severity (CMI)

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Sum of RWPs of all patients discharged

Divided by number of discharges (patients)


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Rescue (cont’d)

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To run CM reports in CHCS:

1. After logging into CHCS, select ORM = Output Reports Menu

2. Select EOUT = Encoder-Grouper Output Menu

3. Select one of the reports below:

1 (460) No of Dispositions and Days Data by DRG 2 (461) Inputs Who Exceed DRG LOS 3 (462) No of Dispositions and Days Data by Category 4 (463) Records with DRGs 468, 469 or 470 5 (464) Case Mix Deviation from Expected Wt 6 (469) Patient Summary 7 (204) Clinical Records with Forced (Override) Flag 8 Batched Records Without DRGs 9 Final Diagnoses, Procedures, & DRG Report


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Rescue (cont’d)

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DRG Analysis Report

RWP

DRG

# of patients by DRG


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POA Indicators

There are five POA indicators. Y = Yes

N = No

U = Unknown (documentation insufficient)

W = Unable to determine if diagnosis was present at the time of admission

1 = Exempt, indicates specific code is on the exempt list


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Assessing POA Status

Scenario: Patient develops “acute cystitis” 3 days into the hospitalization.

Question: What is the POA indicator?

Discussion: Although the MS-DRG assignment flags the cystitis as a “CC,” when it comes to reimbursement, payment will be re-calculated as if the cystitis were not present (no CC) and the case will be re-grouped to a different (lower paying) MS-DRG by the payer.

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Is a query necessary? Perhaps the cystitis was present but not documented.

2010 UBO/UBU ConferenceTurning Knowledge Into Action Assessing POA Status (cont’d)

Scenario: Patient with Diabetes Mellitus developed uncontrolled diabetes on day 3 of the hospitalization.

Question: What is the POA indicator?

Discussion: Assign “Y” if all parts of the combination code were present on admission with diabetic nephropathy is admitted with uncontrolled diabetes).

Assign “N” if any part of the combination code was not present on admission (e.g., obstructive chronic bronchitis w/acute exacerbation and the exacerbation was not present on admission; asthma patient develops status asthmaticus after admission).

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Analyzing a Diagnosis for POA Status

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Coding Guidelines for POA

Distinguishes between pre-existing conditions and hospital-incurred complications on inpatient claims

Conditions which develop during an outpatient encounter, including Emergency Room (ER) encounters, or ambulatory surgery are considered present on admission.

Note: For the POA Reporting Guidelines and POA exempt list, see page 100 of the Official Coding Guidelines for ICD-9-CM. http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf


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Pitfall – Loss of Revenue

PDX 428.31 PDX 428.31

2°DX 427.31 2°DX 427.31

486 * 491.21 *

DRG 291 DRG 292

Heart Failure & Shock Heart Failure & Shock

w/MCC w/CC

RWP 1.4872 RWP 0.9164 PPS $12,904 PPS $7,951

FY09


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Pitfall – Loss of Revenue (cont’d)

PDX 482.41 PDX 482.41

2°DX 599.0 * 2°DX 496.0

DRG 178 DRG 179

Respiratory Infection Respiratory Infection

w/CC w/No CC/MCC

RWP 1.8230 RWP 1.0813

PPS $15,818 PPS $9,382

FY09


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Review of Rescue Attempts

Clinical Documentation Improvement (CDI)Accurate POA selectionMaster the Physician Query Process


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Rescue Attempt – CDI

Clarify discrepancies found between the Discharge Summary and doctor notes during admission.

Coders should utilize ancillary reports as clues to initiate physician queries for clarification.

Common Documentation Documentation (specificity)

Chest Pain GERD, non-cardiac pain, type of angina

Nursing notes state redness and/or breakdown at pressure points

Decubitus Ulcer: site and stage

Infiltrates on CXR, Increased MBC, +sputum cultures, fever, dyspnea

Pneumonia: possible/probable organism and/or bacterial, viral or aspiration

2010 UBO/UBU ConferenceTurning Knowledge Into Action Rescue Attempt – POA accuracy

Coders must Perform detailed review and analysis of the record Assign POA accurately

– Differentiate between Conditions/complications developed during the

hospitalization Conditions/complications prior to the admission order

(review ER encounter and H/P exam)– If documentation “conflicting, inconsistent or unclear”

Query physician Issue must be resolved by the provider

Don’t forget ramifications of CC/MCC

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Rescue Attempt – Physician Query

Clarify clinical relationship between– Clinical findings and – Diagnosis implied by the clinical management

(of the patient) Common Query Topics Requiring Clarification

– Bacteremia versus Septicemia– Blood loss anemia– Diabetes Mellitus, type and manifestation– Septicemia, Sepsis, and Urosepsis

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Summation

Documentation is critical to assigning the appropriate diagnoses and procedure codes.– Coding secondary diagnoses is very important!– Don’t forget the “adjectives”!

Don’t forget– Official Coding Guidelines (civilian sector) – Military Health System Guidelines for Inpatient Coding

Granularity you need (patient care, research, etc.) The $$$ your MTF deserves!

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Questions

2010 ubo/ubu conference health budgets & financial policy 111 briefing: common coding pitfalls...

Documents

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msdrg logic msdrg assignment

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